O   IIWARUS  3 

HEALTH 
SCIKHCF5 
LIBnAitY 


PREPARATORY 

AND   AFTER   TREATMENT 

IN    OPERATIVE    CASES 


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PREPARATORY 

AND  AFTER  TREATMENT 

IN  OPERATIVE  CASES 


BY 
HERMAN  A.   HAUBOLD,  M.D. 

CLINICAL     PROFESSOR     IN     SURGERY     AND    DEMONSTRATOR     OF     OPERATIVE 

SURGERY,    NEW    YORK    UNIVERSITY    AND    BELLEVUE    HOSPITAL 

MEDICAL    COLLEGE,    NEW    YORK  ;     VISITING     SURGEON 

HARLEM     AND     NEW    YORK     RED     CROSS 

HOSPITALS,    NEW    YORK,    ETC. 


WITH   FOUR  HUNDRED   AND   TWENTY-NINE  ILLUSTRATIONS 


NEW  YORK  AND  LONDON 

D.  APPLETON  AND  COMPANY 

1910 


Copyright,  1910,  by 
D.  APPLETON  AND  COMPANY 


PRINTED  AT  THE  APPLETON  PRESS 
NEW  YORK,  U.  S.  A. 


TO 
PROFESSOR  JOSEPH  D.   BRYANT,  M.D.,  LL.D. 

IN    RECOGNITION    OF    THE    DETERMINING 

GUIDANCE    EXTENDED,   IN    THE    FIELD 

OF   WHICH    THIS    BOOK    SPEAKS,   TO 

THE  AUTHOR 


INTRODUCTION 

The  relationship  between  the  physician — i.e.,  the  general  prac- 
titioner-— and  the  surgeon  has  undergone  a  radical  change  within 
the  recollection  of  the  writer.  It  is  not  so  very  long  ago  -that  the 
practitioner  was  permitted  to  stand  meekly  aside  as  the  eminent 
surgeon  walked  out  of  the  patient's  house,  after  pouring  forth 
great  wisdom  to  the  gaping  family,  and  later  act  the  part  of  a 
human  phonograph  reiterating  again  and  again  the  oracular  state- 
ments of  the  surgeon. 

Since  then  the  practitioner's  early  educational  opportunities 
have  been  much  increased.  He  is  better  educated,  better  equipped 
and  occupies  a  position  toward  his  patient  and  the  surgeon  which  is 
no  longer  as  objectionable  as  obtained  previously.  However,  there 
is  still  room  for  improvement  in  this  regard,  and  the  writer  feels 
that  the  education  given  the  practitioner  as  the  outcome  of  methods 
of  teaching  surgical  technic  is  not  such  as  to  place  him  in  the 
precise  position  which  is  his  due. 

The  writer  canvassed  the  position  as  to  just  what  the  fallacy 
in  the  relationship  of  the  practitioner  to  the  surgeon  is,  in  the  fol- 
lowing way.  A  number  of  surgeons  of  ages  ranging  between  thirty- 
five  and  forty-five  were  asked,  "  How  do  you  feel  when  a  practi- 
tioner calls  you  on  the  wire  to  do  at  once  a  celiotomy?  Do  you 
feel  that  you  can  safely  go  with  only  instruments  and  suture  mate- 
rial and  expect  to  find  everything  in  proper  shape  for  operation 
even  though  the  practitioner  tells  you  everything  will  be  ready  ?  " 

The  answer  was  invariably  in  the  negative,  except  in  those  in- 
stances where  the  surgeon  had  repeatedly  done  work  for  a  given 
practitioner. 

Further  discussion  brought  out  that  the  surgeon  felt  that  the 
feeling  of  apprehension  was  qualified  by  these  considerations ;  that 
if  the  practitioner  had  recently  finished  a  term  as  interne  on  the 


viii  INTRODUCTION 

surgical  service  of  a  hospital,  things  were  apt  to  be  in  reliable 
shape ;  if  he  had  had  a  medical  service  they  were  not.  If  he  had 
been  in  practice  for  five  years  and  had  not  had  ample  opportunity 
to  take  part  in  surgical  procedures  he  would  also  probably  make 
defective  preparation.  If  he  had  been  in  general  practice  for  ten 
or  more  years  it  was  believed  that  minute  instructions  were  neces- 
sary. As  to  the  reliability  of  the  after  treatment  in  the  hands  of 
the  general  practitioner,  the  belief  seemed  to  be  universal  that, 
while  the  physician  was  apt  to  be  able  to  take  good  care  of  the  gen- 
eral indications  as  the  outcome  of  his  experience,  the  care  of  the 
wound  itself  would  call  for  more  exact  instructions. 

As  a  rule,  a  practitioner  is  not  in  a  position  to  control  cases 
of  the  kind  which  require  major  operations,  during  the  first  five 
years  of  practice,  for  obvious  reasons,  and  by  the  time  his  position 
becomes  such  that  he  can,  as  the  outcome  of  hard  work  in  a  general 
practice,  he  has  neglected  to  maintain  familiarity  with  the  tech- 
nic of  operative  work. 

It  is  the  intention  of  the  writer  to  furnish  a  work  from  which 
the  practitioner  can  draw  information  with  regard  to  the  handling 
of  a  case  to  be  operated  upon  from  the  time  the  decision  to  operate 
is  reached  up  to  the  making  of  the  incision,  and  then  take  up  the 
case  again  from  the  time  the  operative  technic  is  ended  until 
recovery  is  complete. 

It  is  to  be  regretted  that  human  nature  leans  toward  unusual 
and  peculiar  indulgences.  If  the  science  of  healing  has  established 
anything,  it  is  proven  that  infection  of  operative  wounds  is  due 
to  contamination.  This  is  prevented  by  sterilization  of  the  field 
of  operation  and  all  that  comes  in  contact  with  it,  and  by  measures 
which  are  firmly  established  and  which  universally  achieve  the 
object.  Yet  one  need  only  go  into  the  operating  rooms  of  a  num- 
ber of  surgeons  to  see  a  frightened  assistant  being  scolded  by  the 
operator  for  not  having  taken  the  peculiar  precaution  which  he 
happens  to  favor  in  the  technic  of  anti-  or  asepsis.  This  pecul- 
iarity, the  writer  is  free  to  say,  is  not  infrequently  the  outcome 
of  a  desire  to  pose  beyond  the  measure  of  most  men,  and  one  which 
it  would  be  well  to  have  the  surgeon  control.     The  fact  is,  that 


INTRODUCTION  ix 

the  object  is  attained  in  many  ways,  each  of  which  has  its  special 
field  of  usefulness,  and  in  this  connection  it  is  the  vriter's  desire 
to  be  of  aid  to  the  surgeon  in  bringing  out  the  applicability  of  cer- 
tain methods  under  certain  circumstances.  For  instance,  towels, 
etc.,  are  certainly  rendered  absolutely  sterile  by  heat,  yet  the  same 
object  is  obtained  by  immersing  them  in  a  solution  of  mercuric 
bichlorid  for  a  long  time.  It  need  not  call  forth  a  dissertation 
on  heat  sterilization  from  the  surgeon  if  he  be  called  to  operate 
on  a  case  where  the  conditions  made  heat  sterilization  less  certain 
than  the  use  of  wet  bichlorid  towels.  Especially  is  this  true  if  the 
surgeon  is  called  upon  to  operate  under  conditions  where  the  neces- 
sary apparatus  is  not  available.  The  ingenuity  of  the  practitioner 
is  here  called  into  play,  and  this  work  is  intended  to  aid  him  in 
making  efficient  preparation,  and  show  the  surgeon  how  he  can 
obtain  the  desired  result  under  the  circumstances. 

Again,  while  asepsis  has  replaced  very  largely  antisepsis,  the 
writer  believes  that  there  are  certain  conditions  which  make  more 
desirable  the  use  of  antiseptic  measures,  an  opinion  in  which  he 
does  not  stand  alone. 

In  some  instances  the  ultimate  result  of  an  operative  effort 
is  marred  by  avoidable  sequels.  It  is  intended  to  include  here 
advice  by  which  this  may  be  avoided. 

During  the  transitional  stage  following  the  more  complete  edu- 
cation of  the  candidate  for  the  practice  of  the  healing  art,  a  spirit 
of  commercialism  crept  into  the  profession.  The  practitioner  felt 
that  he  was  acting  the  part  of  a  feeder  to  the  surgeon.  The  family 
paid  him  a  small  fee  for  each  visit  during  the  time  the  diagnosis 
was  being  made,  and  when  informed  that  operation  was  necessary, 
hoarded  together  their  money  to  meet  the  cost  of  the  operation. 
In  many  instances  the  physician  not  only  lost  his  case  but  was 
ultimately  permitted  to  carry  out  the  end  treatment  at  a  nominal 
pay,  which  in  many  instances  was  not  forthcoming  because  the 
funds  of  the  patient  had  been  exhausted  in  paying  the  surgeon. 
The  practitioner  then  took  his  patient  to  the  surgeon,  arranged 
for  the  fee  to  be  charged,  but  exacted  that  he  bo  given  a  certain 
proportion  of  the  fee  in  compensation  for  bringing  the  case.     How 


X  INTRODUCTION 

far  this  percentage  business  has  gone  it  is  of  course  difficult  to 
say.  However,  the  concealment  of  an  infirmity  never  contributes 
to  its  cure,  and  there  can  be  no  doubt  that  this  sort  of  thing  has 
been  and  is  constantly  done. 

Much  of  this  is  due  to  the  fact  that  neither  the  practitioner 
nor  the  patient  have  been  properly  educated  in  the  matter.  The 
practitioner  has  not  devoted  much  energy  to  keeping  in  touch  with 
modern  methods  of  preparing  patients  for  operation,  and  the 
patient  has  not  been  taught  to  understand  that  the  work  connected 
with  or  the  services  necessary  in  this  regard  is  special  work  and 
demands  a  special  fee.  More  so  is  this  true  of  the  after  treatment 
of  operative  cases.  The  surgeon  does  his  operation,  takes  the  fee, 
and  the  practitioner  is  compelled  to  carry  out  the  after  treatment 
of  the  case  at  the  usual  rate  of  charge  for  a  visit.  Manifestly  this 
is  not  an  equable  arrangement,  and  it  certainly  stands  in  a  causa- 
tive relationshijD  to  the  methods  of  handling  the  financial  end  of 
the  surgical  proposition  in  a  manner  from  which  most  men  shrink, 
even  though  it  would  appear  that  this  was  the  only  way  of  treating 
the  practitioner  fairly. 

In  cases  which  do  not  need  immediate  operation  the  surgeon 
not  infrequently  sends  to  the  patient  a  nurse  who  is  familiar  with 
the  work  necessary  for  the  preparation  of  the  patient,  the  operat- 
ing room,  and  the  apparatus  necessary.  In  some  instances  the 
surgeon  sends  an  assistant  who  makes  the  necessary  preparations. 
Again  the  general  practitioner  is  placed  in  an  undesirable  posi- 
tion, and  one  which  need  not  be.  The  general  practitioner  should 
be  in  the  position  to  attend  to  these  matters  himself,  and  thus 
occupy  the  position  toward  the  patient  and  the  surgeon  that  he 
should. 

As  far  as  the  preparation  is  concerned  of  the  patient,  who  suf- 
fers from  some  complication  requiring  special  preparation,  the 
work  to  be  submitted  here  is  intended  to  act  as  a  guide,  taking 
up  nephritis,  diabetes,  obesity,  tuberculosis,  etc.,  in  connection  with 
contemplated  operations. 

If  the  patient  and  the  family  are  made  to  understand  that  the 
surgeon  will  operate,  that  his  advice  with  regard  to  the  preliminary 


INTRODUCTION  XI 

and  after  treatment  is  at  the  patient's  disposition  if  required,  but 
that  the  real  carrying  out  of  the  measures  indicated  are  in  the 
hands  of  the  practitioner,  who  is  thus  an  integral  part  of  the  pro- 
cedure, and  that  this  work  is  entitled  to  special  financial  remunera- 
tion, the  problem  of  what  part  of  the  entire  fee  available  shall  go 
to  the  surgeon  is  solved,  and  there  need  be  no  ignominy  entailed 
upon  anyone. 

If  this  work  achieves  nothing  beyond  placing  the  relationship 
of  the  practitioner  and  the  surgeon  to  each  other  and  of  both  to- 
ward the  patient,  on  a  more  equable  and  proper  basis,  the  writer 
will  feel  that  .a  worthy  object  has  been  attained. 

The  writer  acknowledges  most  gratefully  the  assistance  given 
him  by  Dr.  John  F.  Connors,  who  has  been  concerned  in  much  of 
the  work  necessary  to  make  this  book. 

The  house  staff  of  the  Harlem  Hospital  of  K^ew  York,  together 
with  the  nurses  engaged  there,  have  been  of  signal  service  in  pro- 
curing the  material  depicted  in  many  of  the  illustrations  given. 
Their  kindly  offices  are  herewith  gratefully  acknowledged.  Mr. 
I.  Steinberg  of  this  city  gave  valuable  aid  to  the  writer  with 
respect  to  the  art  of  photography,  which  has  been  considerably 
employed  in  the  illustrations.  This  assistance  is  herewith 
acknowledged.  The  writer  also  wishes  to  commend  the  publish- 
ers for  kindly  assistance  given,  and  thanks  them  for  the  skillful 
execution  of  their  portion  of  this  work. 


CONTENTS 


CHAPTER   I 

PAGES 

General  Considerations 1-37 

Cases  in  which  operations  are  not  urgent,  1 ;  Recording  the  his- 
tory, 2;  Office  arrangement,  6;  Bronchitis,  10;  Pulmonary  tubercu- 
losis, 11;  Tuberculosis  of  glands,  bones  and  other  parts,  12; 
Nephritis,  13;  Cardiac  and  arterial  diseases,  15;  Rheumatism  and 
gout,  18;  Syphilis,  20;  Hemophilia,  21;  Alcohol,  23;  Tobacco,  28; 
Morphin,  cocain,  etc.,  30;  Obesity,  31;  Diabetes,  33;  Training  of 
tolerance  for  manipulation  of  cavities,  36. 


CHAPTER    II 

Preparation  of  the  Patient 38-55 

The  sick  room,  38;  The  bed,  39;  Catharsis,  41;  General  prepara- 
tion of  patient:  Kocher's  method,  42;  Moynihan's  method,  43; 
Diet,  44;  Preparation  of  the  operative  field  in  clean  cases,  46; 
Preparation  of  the  operative  field  in  infected  cases,  51;  Attire  of 
patient  about  to  be  removed  to  operating  room,  53. 


CHAPTER    III 

Sterilization  and  Preparation  op  Instruments  and  Dressings       .       56-84 

Sterilization  of  instruments,  56;  General  sterilization,  60;  Steam 
dressing  sterilizers,  62;  Requisites  for  a  major  operation,  66; 
Gowns,  68;  Caps,  68;  Rubber  gloves,  60;  Soap.  69;  Nail  brushes, 
69;  Calcium  chlorid,  70;  Gauze  pads,  70;  Wipes,  72;  Sterilized 
cotton,  75;  Gauze  for  dressings,  75;  Iodoform  gauze,  76;  Balsam 
of  Peru  gauze,  76;  Combined  dressing,  77;  Many-tailed  binder, 
80;  T-binder,  80;  Cigarette  drains,  80;  Rubber  tube  drains,  80 
Sterilized  salt,  81;  Sterile  towels,  81;  Self -retaining  catheters,  81 
Lubricating  agents,  82;  Bath  thermometer.  82;  Rectal  tube,  82 
Douche  bags,  83;  Celiotomy  sheet,  84;  Rubber  sheets,  84;  Vulvar 
pads,  84. 


xiv  CONTENTS 


CHAPTER   IV 

PAGES 

Suture  and  Ligature  Material    ....;...     85-103 

Absorbable  and  non-absorbable  ligature  material,  85;  Absorbable 
ligature  material:  Catgut,  86;  Plain  catgut,  88;  Heating  of  cat- 
gut in  fatty  liquid,  89;  Chroniieized  catgut,  90;  Iodin  catgut,  95; 
Kangaroo  tendon,  96;  Non-absorbable  suture  material;  Silk-worm 
gut,  97;  Silk,  98;  Pagenstecher  thread,  100;  Horsehair,  102;  Silver 
and  gold  wire,  102. 


CHAPTER    V 

Water  and  Cleansing  Solutions  .        .......  104-123 

Water:  Sterilization  of  Avater,  104;  Apparatus  for  sterilization 
of  water,  105;  Outfit  for  sterilization,  110;  Handling  of  water 
during  operations,  114;  Antiseptic  solutions — Carbolic  acid,  117; 
Mercury,  119;  Zinc  chlorid,  etc.,  120;  Thiersch's  fluid,  120;  Peroxid 
of  hydrogen,  121;    Plain  sterile  water,  121;   Saline  solution,  122. 


CHAPTER    VI 


The  Preparation  of  Operator  and  the  Assistants    ....  124-138 

The  operating  suits,  125;  Cleansing  the  hands,  126;  Canton  flannel 
gloves,  132;  Gowns,  132;  Gloves  during  operations,  133;  Caps  and 
masks,  136. 


CHAPTER    VII 

The  Operating  Room 139-185 

The   hospital   operating  room,    139;    Artificial   illumination,    141 
Operating  table,  142;  Dressing  table,  146;  Instrument  table,  148 
Narcotist's    table,    148;    Adjustable    tray    for    instruments,    148 
Surgeon's  lavatory,   149;   Utensil  sterilizer,   151;    Irrigation,   151 
Arrangement  of  tables,  etc.,  in  operating  room,  152;  Dressing  of 
tables   in   operating   room,    153;    The   operating   table,    153;    The 
instrument  table,  154;   The  anesthetist's  table,  154;   The  adjust- 
able  instrument   tray,  156;    Dressing  table,   158;    Final   prepara- 
tion   of    patient.    160;    Disposition    of    operator,    assistants    and 
nurses  during  the  operation,  169;   The  operating  room  in  private 
practice,  169;  The  operating  table,  173;  Portable  operating  table, 
175;   The  extemporized  operating  table,   177;    Sterile  water,  180; 
Suture  and  ligature  material,  185. 


CONTENTS  XV 


CHAPTER   VIII 

PAGES 

Drainage  of  Operative  Wounds   ........  186-200 

Drainage  in  uninfected  eases,  187;  Drainage  in  infected  cases, 
188;  Drainage  agents:  Tube  drainage,  189;  Silk-worm  gut  drain- 
age, 193;  Catgut  drainage,  194;  Rubber  tissue  drainage,  195; 
Textile  fabric  drainage,  196. 


CHAPTER    IX 

Suturing  of  Operative  Wounds 201-216 

Needles,  203;  Needle  holders,  207;  Suturing  of  wounds:  The  con- 
tinuous suture,  211;  The  interrupted  suture,  215;  Harelip  pins, 
216. 

CHAPTER    X 

The  Dressing  of  Operative  Wounds 217-226 

Antiseptic  powders,  217;  Iodoform  and  its  modifications,  220;  Ap- 
plication of  powder,  220;  The  protective  dressing,  221;  Gauze  for 
dressings,  223. 

CHAPTER    XI 

Shock  and  Secondary  Hemorrhage  following  Operations       .        .  227-271 

Shock  following  operations,  227;  -Shock  bed,  229;  Treatment  of 
shock,  233;  Hypodermic  injections,  235;  Mechanical  pressure, 
236;  Transfusion,  237;  The  direct  transfusion  of  blood,  238;  The 
suture  method  of  blood-vessel  anastomosis,  238;  The  cannula 
method  of  blood-vessel  anastomosis,  242;  General  management 
of  a  transfusion,  246;  The  donor,  250;  The  recipient,  253;  Infu- 
sion, 259;  Needling  of  artery,  263;  Hypodermoclysis,  263;  En- 
teroclysis,  265;  Secondary  hemorrhage  following  operations,  267; 
The  Mikulicz  tampon,  268;   Removal  of  Mikulicz  tampon,  268. 


CHAPTER    XII 

Vomiting  and  Acute  Dilatation  of  Stomach  and  Gut      .        .        .  272-282 

Postoperative  vomiting,  272;   Character  of  vomited  matter,  276; 
Acute  dilatation  of  stomach* and  gut,  277;   Treatment,  282. 

CHAPTER    XIII 

Thirst  and  Pain 283-287 

Thirst,  283;   Treatment  of  thirst,  283;  Pain,  285. 


xvi  CONTENTS 

CHAPTER   XIV 

PAGES 

Feeding  after  Operations 28S-297 

Feeding  by  mouth,  288;  Rectal  feeding,  291;  Formulae  for  rectal 
feeding,  293. 

CHAPTER    XV 

Care  of  Wounds  after  Operations 298-310 

Time  of  changing  dressings,  299;  Preparation  for  change  of  dress- 
ing, 300;  Exposing  the  wound,  302;  Removal  of  stitches,  304; 
Cleansing  and  drainage  of  infected  wounds,  305. 


CHAPTER    XVI 

Operations  on  the  Scalp,  Skull  and  Brain 311-357 

Operations  on  the  scalp:  Preparation  of  narcotist,  311;  Prepara- 
tion of  scalp,  312;  Care  of  wounds,  314;  Operations  on  the 
cranium,  316;  Kroenlein  construction,  316;  Care  of  wounds  of 
cranial  bones,  326;  Operations  involving  cranial  contents,  328; 
Bone  necrosis,  332;  Secondary  hemorrhage,  333;  Retention  of 
cerebrospinal  fluid,  335;  Edema  and  softening  of  the  brain  sub- 
stance, 336;  Discharge  of  cerebrospinal  fluid,  341;  Brain  pro- 
lapse, 343;  The  retaining  bandage,  348;  Mastoid  operations:  The 
simple  operation,  352;  The  radical  ojteration,  355;  Results  of 
after-treatment,  355;  Intracranial  neurectomy,  356. 


CHAPTER   XVII 
Operations  on  the  Face       . 358-372 

Rhinoplasty,    364;    Osteoplastic    rhinoplasty,    366;    Harelip    and 
cleft  palate,   367;    Miscellaneous   operations  in  the   mouth,   369. 


CHAPTER    XVIII 
Operations  on  the  Neck .        .  373-394 

Torticollis,  373;  Tuberculosis  of  cervical  lymph  glands,  375; 
Operations  on  the  larynx  and  trachea:  Intubation  of  the  larynx, 
378;  Tracheotomy,  380;  Laryngectomy,  383;  Thyroidectomy — 
The  rise  of  temperature,  388;  Pneumonia,  388;  Tetany  and  chronic 
myxedema,  389;  Acute  myxedema,  389;  Chronic  postoperative 
myxedema,  389;  Treatment  of  tetany  and  cachexia,  389;  Exo- 
thyropexy,  391 ;  Drainage  and  packing  of  cysts  of  the  thyroid, 
391;  Esophagotomy,  392;  The  care  of  the  wound,  393. 


CONTENTS  xvii 

CHAPTER   XIX 

PAGES 

Operations  on  the  Thorax 395-415 

Excision  of  the  breast,  395;  Thoracotomy — Simple  incision,  399; 
Aspiration  with  drainage,  401;  Thoracoplasty,  406;  Decortication 
of  the  lung,  408;  Resection  of  large  surfaces  of  the  thoracic  wall, 
408;   The  deformity,  413. 

CHAPTER   XX 

Operations  on  the  Spinal  Column 416-421 

Laminectomy,  416;   Tuberculous  osteomyelitis  of  the  spine,  420. 

CHAPTER   XXI 

Operations  on  the  Abdomen ■  .        .        .  422-450 

Celiotomy,  422;  Special  preparation  of  the  gastro- intestinal  canal, 
424;  Sterile  diet,  430;  Drainage,  433;  Closure  of  abdominal 
wound,  435;  Drainage  of  superficial  wound,  436;  The  protective 
dressing,  436;  The  after-treatment  following  celiotomy,  439; 
Thirst,  442;  If  vomiting  persists,  442;  Nephritis,  442;  Retention 
of  urine,  443;  The  administration  of  opiates,  443;  Catharsis  after 
celiotomy,  444;  Tympanitis,  445;  The  administration  of  solid  food, 
446;   The  time  of  leaving  the  bed,  447;   Removal  of  sutures,  448. 

CHAPTER    XXII 

Operations  on  the  Abdomen:  Peritonitis  following  Celiotomy     .  451-460 

Prevention  of  peritonitis,  451;  Flushing  of  the  peritoneum,  455; 
Treatment  of  peritonitis,  456;  The  Murphy  treatment,  457. 

CHAPTER   XXIII 

Operations  on  the  Abdomen:  Complications  following  Celiotomy  .  461-480 

Lung  complications,  461;  Parotitis,  465;  Hematemesis,  470;  Phle- 
bitis and  thrombosis,  470;  Adhesions  following  celiotomy,  473; 
Abdominal  belts  and  supporters,  475. 


CHAPTER   XXIV 

Operations  on  the  Abdomen:  Operations  on  the  Stomach      .        .  481-493 

Gastrostomy,    481;    Gastroenterostomy,    487;     Hemorrhage,    488; 
Regurgitant  vomiting,  489;    Intestinal  obstruction,  490;    Ulcer  of 
the  jejunum,  491;   Diarrhea,  491;   Gastrectomy,  491. 
2 


Xviii  CONTENTS 

CHAPTER   XXV 

PAGES 

Operations  on  the  Abdomen:  Operations  on  the  Intestines  .        .  494-507 

Enterectomy.  etc.,  494;  The  diet,  495;  Catharsis,  495;  Fecal  fis- 
tula, 496;  Appendectomy,  496;  Appendicostomy,  498;  Colostomy, 
499;   Colostomy  pad,  502;   Colectomy,  505. 

CBAPTER   XXVI 

Operations  on  the  Abdomen:    Operations  on  Liver  and  Female 

Pelvic  Organs 508-520 

Hydatid  cyst,  508;  Hepatic  abscess,  509;  Resection  of  liver,  511; 
Operations  on  the  gall-bladder  and  biliary  passages,  512;  chole- 
cystotomy,  513;  Cholecystectomy,  515;  Hepaticostomy,  chole- 
docotomy,  chole  and  cholecystenterostomy,  515;  Biliary  fistula, 
517;  Transperitoneal  operations  on  the  uterus  and.adnexa;  Sal- 
pyngectomy,  518;  Ovariotomy,  hysterectomy,  hysteromyomec- 
tomy,  519. 

CHAPTER    XXVII 

Gynecological  Operations  by  the  Perineal  Route    ....  521-540 

-  Position  of  the  patient,  521;  Isolation  of  the  operative  field.  524; 
Irrigation,  525;  Care  during  convalescence,  526;  The  care  of  the 
wound,  527;  Vaginal  drainage  of  pelvic  abscess,  529;  Vaginal 
hysterectomy,  532;  Fecal  or  urinary  fistulse,  537;  Cystitis,  537. 

CHAPTER    XXVIII 

Operations  on  the  Rectum  and  Anus  ...  ...  541-555 

Operations  on  the  rectum  by  the  sacral  route,  542;  Operations 
on  the  anus  and  rectum  by  the  perineal  route,  548;  Fistula  in 
ano,  550;  Removal  of  hemorrhoids,  552;  Prolapse  of  rectum, 
perineal  proctectomy   and  excision  of  tumors   from  rectum,  554. 


CHAPTER    XXIX 

Operations  on  Kidney  and  Ureter 556-565 

Operations  on  the  kidney,  556;  Nephropexy,  557;  Nephrotomy — 
Renal  colic,  560;  Urinary  fistula,  561;  Nephrectomy — Uremia,  562; 
Peritonitis,  563;  Operations  on  the  ureter — The  position  of  the 
patient,  564;  Urinary  fistula,  564;  Grafting  of  ureter  into  bladder, 
564. 


CONTENTS  xix 


CHAPTER    XXX 

PAGES 

Operations  on  the  Bladder  and  Prostate  Gland      ....  566-578 

Operations  on  the  bladder:  Suprapubic  cystotomy,  566;  Tem- 
porary suprapubic  drainage,  567;  Permanent  suprapubic  drainage 
following  cystotomy,  571;  Perineal  pi-ostatectomy:  The  prepara- 
tion of  the  patient,  573;  The  position  of  the  patient,  574;  Drain- 
age, 575;   Cleansing  of  bladder,  577. 


CHAPTER   XXXI 

Operations  on  the  Scrotum  and  Penis 579-5J 

Hydrocele,  579;  Castration,  580;  Varicocele,  580;  Circumcision, 
582;  Plastic  operations  on  the  penis,  583;  Urethrotomy  for 
stricture,  584. 


CHAPTER    XXXII 

Operations  on  the  Extremities .        .  589-611 

Dupuytren's  contraction,  589;  Hallux  valgus,  591;  Flat-foot,  593; 
Club-foot,  597;  Osteotomy,  600;  Resection  and  excision  of  joints, 
601;   Amputations,  606. 


CHAPTER    XXXIII 

Artificial  Limbs    .  612-629 

Instep  amputations,  616;  Retracted  heels,  618;  Ankle-joint  ampu- 
tations, 619;  Leg  amputations,  621;  Knee-bearing  stumps,  623; 
Thigh  stumps,  625;  Hip- joint  amputations,  628;  Amputations  of 
upper  extremities,  628. 


CHAPTER    XXXIV 

Miscellaneous  Operations 630-639 

Fracture  of  patella,  630;   Union  of  fractured  bones,  633;   Nailing 
the  neck  of  the  femur,  634;   Skin-grafting,  636. 


INDEX       ....... 641-650 


LIST  OF   ILLUSTRATIONS 


practice 


1.  Front    view   of   history    card     . 

2.  Reverse  side  of  history  card     . 

3.  History  card  for  urinary  examinations 

4.  History  card  for  pathological  report 

5.  Office   equipment  .... 

6.  Office   equipment  .... 

7.  Office   equipment  .... 

8.  A  simple  form  of  consulting  and  reception  room.     (Kelly.) 

9.  Arrangement  of  examining  room  separate  from  the  consulting 

(Kelly.) 

10.  Bed  suitable  for  abdominal  cases     . 

11.  Bed  suitable  for  head  cases 

12.  Arrangement  of  bed  in  sick  room  in  private 

13.  Kelly  pads 

14.  Rubber  sponge   for   cleansing  skin   . 

15.  Patient  attired  for  conveyance  to  operating 

16.  Instrument  sterilizer 

17.  Portable  instrument  sterilizer  . 

18.  Glass  tube  with  knives  for  steam  sterilization 

19.  Single  knife  in  glass  tube  for  sterilization 

20.  Rack  for  holding  knives  for  sterilization 

21.  Steam  pressure  sterilizer  .... 

22.  Sectional  view  of  steam  pressure  sterilizer 

23.  Gauze  pad  and  wipes  of  two  sizes  . 

24.  Gauze  for  making   wipe     .... 

25.  Gauze  folded  once 

26.  Gauze  folded  twice 

27.  Gauze  folded  one-third  length  . 

28.  Gauze  strip  folded  two-thirds  of  length  . 

29.  Manner  of  holding  gauze  preliminary  to   invi 

30.  Manner  of  inverting  folded  gauze  strip  . 

31.  Gauze  wipe  completed.     (Front  view.)     . 

32.  Gauze  wipe  completed.     (Back  view.) 

33.  Gauze  roll 

34.  Gauze  for  packing  in  glass  container 

35.  Making  combined   dressing 

36.  Transverse    section    of   combined   dressing 

37.  Many-tailed  abdominal  binder  . 

38.  T-binder 

39.  Sterile  rubber  drainage  tube  in  hermetically  sealed  glass  tube 

40.  Concentrated  salt  solution  in  hermetically  sealed  glass  tube 


ertintr  ed 


PAGE 

3 
3 

4 
4 

7 
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39 
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49 
54 
56 
57 
59 
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70 
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72 
72 
72 
73 
74 


76 
77 
78 
79 
79 
79 
80 
80 
81 


XX11 


LIST   OF   ILLUSTRATIONS 


figiti 

41. 

42. 

43. 

44. 

45. 

46. 

47. 

48. 

49. 

50. 

51. 

52. 

53. 

54. 

55. 

56. 

57. 

58. 

59. 

60. 

61. 

62. 

63. 

64. 

65. 

66. 

67. 

68. 

69. 

70. 

71. 

72. 

73. 

74. 


79. 
80. 
81. 

82. 
83. 
84. 
85. 
86. 
87. 


89. 


tube 


Lubricant  in  collapsible  metal  tube  . 

Bath  thermometer 

Soft  rubber  rectal  tube 

Celiotomy  sheet 

Vulvar  pad  .         .         .         .         .         . 

Catgut  looped  and  ready  for  sterilization 

Catgut  wound  on  bobbin,  ready  for  use  . 

Catgut  coils   in   biniodid   of   mercury 

Convenient   arrangement   of   jars   of   catgut   . 

Apparatus  for  eumolizing  catgut 

Sterile   catgut  in  hermetically  sealed  glass  tube 

Emergency  sutures  with  needle  in  hermetically  sealed 

Kangaroo  tendon  in  hermetically  sealed  glass  tube 

Silk-worm  gut   in  hank     .      '  . 

Iron-dyed  silk-worm  gut  in  glass  tube  . 

Surgeons  silk  wound  on  cardboard  . 

Silk   on  spools.      (Bryant.)        .... 

"Wide-mouthed  bottle   for   ligatures.      (Bryant. 
Braided  white  silk  in  hermetically  sealed  glass  tube 
Twisted  iron-dyed  silk  in  hermetically  sealed  glass  tube 

Pagenstecher  thread   

Silver  wire  in  hermetically  sealed  tube  . 
Apparatus  for  sterile   water      .... 
Water  sterilizer  for  emergency  service  . 
.Apparatus  for  sterilizing  and  cooling  water  . 

Sectional  view  of  Fig.  65 

Complete  sterilizing  plant  assembled 

Plan  of  sterilizing  plant  for  use  in  hospital  . 

Combined  water,  dressing  and  instrument  sterilizer 

Convenient  arrangement  of  pitchers  for  lavage 

Method  of  handling  sterile   water    . 

Drawing  sterile  water  without  risk  of  contamina 

"Wrong  way  to  hold  basin         .... 

Proper  way  of  holding  basin    .... 

Linen   suit   worn   by   surgeon   .... 

Table  with  material  for  cleansing  hands  . 
Wash  stand  used  for  cleansing  hands     . 
Immersion    bowls        ...... 

Canton  flannel  gloves.      (Bryant.)    . 

Hand  and  wrist  covered  with  rubber  glove   . 

Hand  covered  with  rubber  glove,  forearm  bandaged  with  sterile 

Forearm  covered  with  sleeve  of  gown     . 

Ends  of  fingers  covered  with  rubber  finger  cots 

Crile  mask 

Surgeon  attired  for  operation  .... 
Attire  of  "  sterile  "  nurse  .... 
Operating  table  showing  appliances  for  raising  up 

"  kidney  "  position       ..... 
Operating  table  showing  appliances  for  lithotomy 
Operating  table  arranged  for  Hartley  position 


per 


position 


do  men  or  for 


office 


PAGE 

82 

S2 

83 

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84 

87 

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91 

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9S 

99 

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112 

113 

113 

114 

115 

110 

125 

127 

128 

130 

132 

134 

135 

135 

136 

137 

137 

138 


LIST   OF   ILLUSTRATIONS  xxiii 

FIGURE  PAGE 

90.  Operating  table  in  Trendelenburg  position 146 

91.  Table    for    dressings *    .        .         .147 

92.  Table   for  instruments 147 

93.  Narcotist's   table 148 

94.  Adjustable    instrument    tray 149 

95.  Surgeon's   lavatory  149 

96.  Operating  room  utensil  sterilizer 150 

97.  Operating  room  irrigating  apparatus 151 

98.  Diagram  of  arrangement  of  apparatus  and  assistants  during  a  celi- 

otomy operation.      (Bryant.) 152 

99.  Tables,  etc..  used  in  operating  room 153 

100.  Operating  table  covered  with  pads 153 

101.  Instrument  table  covered  with  sterile  towel 154 

102.  Instruments  spread  on  sterile  towel 155 

103.  Instruments  ready  for  use 155 

104.  Table  arranged  with  material  for  narcotist 156 

105.  Adjustable  instrument  tray  covered  with  sterile  pillow  case     .         .  157 

106.  Adjustable  instrument  tray  with  sterile  towel  and   instruments  in 

immediate  use 157 

107.  Dressing  table  arranged  for  extensive  operation 158 

108.  Dressings,  etc.,  protected  by  sterile  sheets 159 

109.  Table  arranged  with  instruments   and  dressings  suitable  for  small 

sanatoria       ............  160 

110.  Carriage  for  transportation  of  patient   to   operating  room,   covered 

with   pad 161 

111.  Carriage  covered  with  blanket  and  small  pillow 161 

112.  Carriage  with  folded  sheet  over  blanket 162 

113.  Patient  placed  on  carriage     " 162 

114.  Restraining  sheet  placed  about  patient 163 

115.  Patient   completely   prepared  for  narcosis 163 

116.  Surrounding  parts  of  operative  field  covered  with  woolen  blankets  .  164 

117.  Woolen  blankets  protected  from  moisture  with  rubber  sheets  .         .  165 

118.  Convenient  arrangement  of  articles  for  final  cleansing  of  skin         .  166 

119.  Rubber  sheets  covered  with  sterile  towels 167 

120.  Operative   field   isolated   by   celiotomy   sheet 168 

121.  Side  view  of  arrangement  of  celiotomy  sheet 168 

122.  Sterile  towels  arranged  in  manner  to  surround  operative  field  .         .  169 

123.  Sterile  towels  applied  to  surroundings  contiguous  to  operative  field  .  170 

124.  Prepared    for    operation.     (Bryant.) 171 

125.  Squier's    portable    operating    table    showing    Trendelenburg    posture 

and  crank      .         .         .         .         . 174 

126.  Method  of  folding  Squier's  portable  operating  table  .         .         .         .174 

127.  Squier's  portable  operating  table  folded   for  transportation       .         .  175 

128.  Squier's  portable  operating  table  arranged  for  lithotomy  position     .  176 

129.  Extemporized  operating  table.     Kitchen  table  covered  with  blanket  .  177 

130.  Extemporized  operating  table  covered  with  blanket  and  rubber  sheet   177 

131.  Small  pillow  and  sheet  on  extemporized  operating  table   .         .         .  178 

132.  Drainage   pad  on  extemporized   operating  table 178 

133.  Kelly  pad  arranged  on  extemporized  operating  table  to  drain   into 

pail        ...  179 


XXIV  LIST  OF   ILLUSTRATIONS 

FIGURE  PAGE 

134.  Clamps  and  uprights  for  lithotomy  position 179 

135.  Clamp   and  stirrup   for  extemporized  table .  180 

136.  Portable  operating  and  instrument  table 180 

137.  Portable  operating  and  instrument  table  folded  for  transportation  .  181 

138.  Flask  filled   with   water 182 

139.  Flask  of  sterile  water  with  rubber  tube  connection  for  irrigation     .  182 

140.  Glass  bulb  connection  in  rubber   tube  to   control   flow  of  irrigating 

fluid 183 

141.  Flask  used  as   irrigator .  184 

142.  Glass  jar  containing  rubber  drainage  tubes 190 

143.  Rubber  drainage  tube  fenestrated  and  safety  pin  attached       .         .  191 

144.  Rubber  drainage  tube  in  situ 192 

145.  Triplex  rubber   drainage   tube 193 

140.  Transverse  section  of  triplex  rubber  drainage  tube       ....  193 

147.  Silk-worm  gut  looped  for  drainage  purposes 194 

148.  Silk-worm  gut  drain  in  situ 195 

149.  Catgut   arranged   for   drainage 196 

150.  Catgut    drain    in  situ 197 

151.  Glass  jar  for  storing  sterile  rubber  tissue 198 

152.  Rubber  tissue  rolled  on  itself  for  drainage  purposes  ....  198 

153.  Rubber  tissue  drain  in  situ 199 

154.  Cigarette   drain 199 

155.  Cigarette  drain  in  situ 200 

156.  Suture   properly  tied 201 

157..    Suture  improperly   tied 202 

158.  Straight    surgical   needle.      (Bryant.) 203 

159.  Half-curved  surgical  needle.      (Bryant.) 203 

160.  Full-curved  surgical  needle.     (Bryant.) 203 

161.  Straight  Hagedorn  needle.      (Bryant.) 204 

162.  Half-curved  Hagedorn  needle.      (Bryant.) 204 

163.  Full-curved  Hagedorn  needle.      (Bryant.) 204 

164.  Needle  wounds 204 

165.  Round  needle  for  approximating  serous  surfaces.      (Kelly.)        .         .  205 

166.  Coe's  needle  with  handle 205 

167.  Hagedorn  needle    with   Gentile  handle 205 

168.  De   Garmo's  femoral   needle 206 

169.  Hartley-Markoe   needle  holder.      (Bryant.) 207 

170.  Sand's  needle  holder.      (Bryant.) 208 

171.  Luer's  needle  holder.      (Bryant.) 208 

172.  Halsted-Leur   needle   holder.     (Bryant.) 208 

173.  Ermold   needle   holder 208 

174.  Kelly  needle   holder.      (Kelly.) 209 

175.  Needle  holder  showing  method  of  grasping  round  needle.     (Kelly.)   .  209 

176.  Continuous  suture  ready  to  be  tied 210 

177.  Continuous  suture  completed  and  tied 211 

178.  Interrupted  suture  properly  introduced  and  tied 211 

179.  Relaxation  sutures  or  tension  sutures 212 

180.  Tension  sutures  threaded  on  buttons 212 

181.  Tension  sutures  looped  over  pledgets  of  gauze 213 

182.  Method  of  introducing  harelip  pins. 213 


LIST   OF   ILLUSTRATIONS 


XXV 


fter 


the  operation 


FIGURE 

183.  Suture  material   looped  over  harelip  pins 

184.  Ends  of  harelip  pins  cut  off  . 

185.  Antiseptic  powder  sprinkler.      (Bryant.) 

186.  Powder  sprinkler  used  in  operating  room 

187.  Flat  gauze  applied  immediately  to  wound 

188.  Fluffed  gauze  placed  over  flat  gauze 

189.  Roll  gauze  applied  over  fluffed  gauze     . 

190.  Combined  dressing  applied  over  roll  gauze 

191.  Shock  bed  with  slip  sheet  and  blocks  . 

192.  Shock  bed  with  foot-end  elevated  . 

193.  Shock  bed  completely  prepared  for  patient 

194.  Bedside  table  with  appliances  used  immediately  a 

195.  Hypodermic    syringes 

190.  Usual  method  of  making  hypodermic  injections 

197.  A  useful  method  of  making  a  hypodermic  injection 

198.  Crile's  inflated  rubber  suit  for  treatment  of  shock.     (Bryant.)   . 

199.  Instruments  used  in  performing  a  transfusion  by  end-to-end  anas- 

tomosis by  the  cannula  method.      (Crile.)  .         .         .         .         . 

200.  Diagram  of  stages  of  end-to- end  anastomosis  of  two  blood  vessels 

by  the   suture   method.      (Crile.) 

201.  Diagram  of  stages  of  end-to-end  anastomosis  of  two  blood  vessels 

by  the  cannula  method.     (Crile.)      ....... 

202.  Diagram  of  arrangement  of  operating  room  for  transfusion.     (Crile.) 

203.  A  clinical  transfusion  in  progress.     (Crile.) 

204.  Opening  the  vein  with  scalpel.      (Bryant.) 

205.  Instruments  employed  in  the  operation  of  infusion.     (Bryant.) 

206.  Apparatus  for  infusion.      (Bryant.) 

207.  Introducing  the  tube   in  infusion      (Bryant.) 

208.  Hypodermoclysis 

209.  Administration  of  saline  solution  into  rectum 

210.  Mikulicz  tampon  in  situ 

211.  Mikulicz   tampon .         .         . 

212.  Mikulicz  tampon  grasped  with  heavy  hysterectomy  forceps 

213.  Mikulicz  tampon  twisted,  ready  for  removal 

214.  Postural  treatment  for  acute  dilatation  of  stomach  and  intestine  . 

215.  Wales'   soft   rubber   rectal    bougie.      (Tattle.) 

216.  Gaaze  in  contact  with  woand 

217.  Angular  probe-pointed   scissors 

218.  Removing  sutures  from  wound       ........ 

219.  Director  introduced  into  wound  in  search  of  infective  secretions 

220.  Method  of  cleansing  an  infected   wound 

221.  Dressing  forceps  introduced  through  wound 

222.  Gauze  drainage  in  situ     . .         . 

223.  Infected  wound  packed  with  gauze  and  sutures  placed  . 

224.  Method  of  isolating  portion  of  scalp 

225.  Rubber  tube,  drainage  of  subaponeurotic  space  of  scalp 

226.  Fissure    of   Sylvius    and    Rolando    outlined    with    nitrate    of    silver. 

(Krause.) 

227.  Kroenlein   construction 

228.  Example  of  frontipetal  type  of  brain.     (Krause.)        . 


PAGE 

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232 
235 
235 
236 
236 

239 

241 


244 
247 
249 
259 
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261 
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304 
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315 


317 
318 

320 


XXVI 


LIST   OF   ILLUSTRATIONS 


ebral 


229.  Example  of  occipitopetal  type  of  brain.     (Krause.)     . 

230.  Location  of  the  insula  and  lateral  ventricles.      (Krause.) 

231.  Area  of  cerebral  softening.     (Krause.)   .... 

232.  Area   of   cerebral   softening.      (Krause.) 
233  Cerebral  prolapse 

234.  Same   as   Fig.   233 

235.  Adhesive   plaster   strips   and  gauze   tapes   for   pressure   on 

prolapse  ......... 

236.  Gauze  pad  applied  to  cerebral  prolapse 

237.  Cerebral  hernia.      (Krause.) 

238.  Single  roller  bandage  of  the  head.     (Foote.)  . 

239.  Single  roller  bandage  of  head  completed.     (Foote.)     . 

240.  Double  roller  bandage  of  the  head.     (Foote.) 

241.  Double  roller  head  bandage  completed.     (Foote.)  . 

242.  Figure  of  eight  bandage  of  the  head.     (Foote.)   . 

243.  Skull  cap   for  delirious  patients 

244.  Applying  aseptic  cap,  First  step.     (Gerster.) 

245.  Applying  aseptic  cap,  Second  step.     (Gerster.) 

246.  Aseptic  cap  held  in  place  with  sterile  gauze.     (Gerster.) 

247.  Dressing  for  wounds  of  face.      (Gerster.) 

248.  Bandaging  upper  portion  of  one  side  of  face.      (Foote.) 

249.  Syringe  for  cleansing  nasopharynx         .... 

250.  Dressing  for  face  and  neck  operations.     (Gerster.) 

251.  Janet-Frank    syringe 

252.  Cleansing  mouth  after  operation 

253.  Left    torticollis,    showing    method    of    fixing   head    after 

(Whitman.) 

254.  Manipulation    of    neck    following    operation    for    torticollis 

Bergmann.) 

255.  Glisson's   sling.      (Von  Bergmann.) 

256.  Dressing  for  extensive  operations  on  neck     . 

257.  Method  of  feeding  infant  after  intubation  . 

258.  Luer's  double  tracheotomy  cannula.     (Von  Bergmann 

259.  Tracheotomy   tube   in   place   and  position   of   patient   after   tr 

otomy 

260.  Cannula  used  for  convalescents  after  tracheotomy.    (Von  Bergmann 

261.  Porier  cannula  used  after  laryngectomy.      (Von  Bergmann.) 

262.  Gussenbauer's   artificial   larynx.      (Bryant.)  .... 

263.  Gluck's  phonation  apparatus  in  place.     (Von  Bergmann.)   . 

264.  Record   syringe 

265.  Appearance  of  wound  after  excision  of  breast.     (Gerster.)  . 

266.  Cuirass  to  hold  dressing  in  place   after   removal   of  breast. 

Bergmann.) 

267.  Method  of  drainage  of  pleural  cavity  after  simple  thoracotom 

268.  Wound  with  drainage  tubes  after  thoracotomy.     (Bryant.) 

269.  Bryant's   aspiration   apparatus.      (Bryant.)    . 

270.  Aspiration  of  pleural  cavity.      (Bryant.) 

271.  Aspiration  of  pleural   cavity.      (Bryant.) 

272.  Aspiration  of  pleural  cavity.     (Bryant.) 

273.  Aspiration  of  pleural  cavity.     (Bryant.) 


oper 


PAGE 

321 

325 

338 

,  339 

,  343 


tion. 


(Von 


ache- 


Von 


345 
346 
347 
348 
349 
350 
351 
351 
352 
358 
359 
359 
360 
360 
363 
364 
370 
371 

373 

374 
374 
377 
379 
380 

381 
382 
384 
385 
386 
390 
396 

397 
400 
400 
401 
402 
402 
403 
404 


LIST   OF   ILLUSTRATIONS  xxvii 

FIGURE  PAGE 

274.  Appearance   of   chest   following   extensive   resection   of   ribs.      (Von 

Bergmann.) 40D 

275.  Fell-O'Dwyer   apparatus   in  action.      (Bryant.)      .....  410 

276.  Forced  respiration.     Fell's  improved  apparatus.      (Bryant.)        .         .  411 

277.  Tracheotomy   tube   and   rings   used   in   forced   artificial   respiration. 

(Bryant.) 411 

278.  Deformity  following  extensive  resection  of  ribs.     (Von  Bergmann.)   413 

279.  Retraction  of  flap  following  thoracoplasty.     (Von  Bergmann.)   .         .  414 

280.  Bulging  of  flap  following  thoracoplasty.     (Von  Bergmann.)       .         .  415 

281.  Gilbert  and  Domenici's  diagram.      (Moynihan.) 426 

282.  Harvey  Cushing's  diagram.      (Moynihan.) 427 

283.  Vessel  for  sterile  diet .         .         .  430 

284.  Arrangement   for  sterilizing  food 431 

285.  Abdominal  dressing  held  in  place  with  adhesive  strips  and  tapes       .  437 

286.  Many-tailed  abdominal  binder  in  situ     .         .         .    .     .         .         .         .  438 

287.  Retaining  bandage  after  celiotomy.      (Bryant.)    .....  439 

288.  Acute  dilatation  of  stomach.     (Campbell  Thomson.)   ....  440 

289.  Method  of  restraining  patient  after  operation 441 

290.  Granulating  wound  ready  for  secondary  suturing 448 

291.  Granulating   celiotomy   wound   approximated  with   adhesive   plaster 

strips 449 

292.  Patient  in  Fowler  position  being  given  the  Murphy  instillation  into 

rectum 459 

293.  Parotitis.     (Rupert  Bucknall.)         .         . 467 

294.  Parotitis.     (Rupert  Bucknall.) 468 

295.  Parotitis.     (Rupert  Bucknall.) 469 

296.  Method  of  strapping  abdomen,  Preliminary  step.      (Kemp.)  .         .  476 

297.  Method  of  strapping  abdomen,- Second  step.     (Kemp.)  ....  477 

298.  Method  of  strapping  of  abdomen,  Final  step.     (Kemp.)        .         .         .  478 

299.  Lines  of  measurement  for  abdominal  belt 478 

300.  Abdominal    supporter 479 

301.  Abdominal   supporter  in  position 479 

302.  Abdominal  supporter  and  corset  combined 479 

303.  Adjusting    lower    segment    of    combined    abdominal    supporter    and 

corset 480 

304.  Adjusting    upper    segment    of    combined    abdominal    supporter    and 

corset 4S0 

305.  Tube  leading  into  stomach  following  gastrostomy  held  in   place     .  482 

306.  Introduction  of  liquid  nourishment  through  gastric  fistula  .         .         .  483 

307.  Soft  rubber  obturator  for  gastric  fistula 484 

308.  Forcing  macerated  beef  through  gastric  fistula 486 

309.  Moynihan's  position  after  gastric  operation 487 

310.  First  step  of  colostomy.     (Tuttle.) 500 

311.  Incision  of  protruding  gut  in  colostomy.      (Tuttle.)    ....  501 

312.  Colostomy  pad  held  in  place  .........  502 

313.  Receptacle  suitable  for  receiving  feces  from  colostomy  opening         .  503 

314.  Emptying  colon  into  receptacle 503 

315.  Cleansing  colon  through  colostomy  opening 504 

316.  Colostomy  pad  with  abdominal  belt 504 

317.  Colostomy  pad  and  ring 505 


xxviil  LIST   OF   ILLUSTRATIONS 

FIGURE  PAGE 

318.  Paul's  tubes  in  situ.      (Moynihan.) 506 

319.  Paul's   tubes.      (Moynihan.) 506 

320.  Sandbag  in  position  for  approach  to  biliary  passages.     (Moynihan.)   512 

321.  Drainage  arrangement  following  cholecystotoniy 513 

322.  Angular  soft  rubber  tube 514 

323.  Patient  in  Trendelenburg  position 520 

324.  Position  of  patient  for  perineal  operation 521 

325.  Clover's   crutch.      (Keyes.) 522 

326.  Adjustable   leg-holders      . .         .522 

327.  Portable   heel    cups 523 

328.  Miller's   sponge   holder.      (Kelly.) 523 

329.  Swedish  hard  rubber  nozzle.    (Kelly.)    : 525 

330.  Curved  volsella  for  holding  cervix.     (Kelly.) 529 

331.  Saw-toothed  traction  forceps.      (Kelly.) 530 

332.  Bozeman's  return  flow  irrigating  tube 530 

333.  Uterine    dressing   forceps 531 

334.  Hysterectomy  clamps  rolled  in  gauze.     (Kelly  and  Noble.)   .         .         .  533 

335.  Vaginal  vault  after  vaginal  hysterectomy.     (Kelly.)   ....  536 

336.  Irrigation  of  bladder  with  two-way  catheter.     (Kelly.)       .         .         .  538 

337.  Method  of  continuous  irrigation  of  bladder.      (Kelly.)        .         .         .  539 

338.  Tuttle's  pneumatic  proctoscope.      (Tuttle.) 541 

339.  Alligator   forceps.      (Tuttle.) 542 

340.  Appearance    of    wound   after   excision   of   rectum   by    sacral    route. 

(Tuttle.) 543 

341.  Appearance  of  artificial  anus.      (Tuttle.) 544 

342.  Kelly's  set  of  instruments  for  treatment  of  wounds  of  rectum  and 

sigmoid.      (Kelly.) 546 

343.  Knee-chest  position.      (Tuttle.) 548 

344.  T-bandage   in  situ.      (Gerster.) 552 

345.  Kemp's    tube 554 

346.  Cleansing  rectum  with  Kemp  tube 555 

347.  Patient  postured  for  approach  to  kidney.     (Von  Bergmann.)     .         .  557 

348.  EdebohFs   air  cushion 557 

349.  Patient  postured  on  air  cushion  for  nephropexy.     (Von  Bergmann.)   558 

350.  Urinal   for  urinary   fistula 562 

351.  Angular   "double   flow"   soft   catheter   for   suprapubic   drainage   of 

bladder 567 

352.  Marion  soft  rubber  apparatus  for  bladder  drainage  and  cleansing     .  568 

353.  Apparatus  for  drainage  and  cleansing  bladder  in  situ  ....  568 

354.  Mushroom  retention  catheter  for  drainage  of  bladder  ....  569 

355.  Specially  constructed  stylet  for  introducing  mushroom  catheter       .  569 

356.  Mushroom  catheter  drawn  over  stylet 570 

357.  Permanent  suprapubic  drainage  tube.     (Keyes.) 571 

358.  Front  view  of  apparatus  for  permanent  suprapubic  drainage  of  blad- 

der.      (Keyes.) 572 

359.  Leg  urinal  used  in  conjunction  with  permanent  suprapubic  drainage 

apparatus.      (Keyes.) 572 

360.  Patient  in  exaggerated  lithotomy  position.      (Bryant.)        .         .         .  574 

361.  Chemise  cannula.     (Bryant.) 575 

362.  Chemise  catheter.     (Bryant.) 575 


LIST   OF   ILLUSTRATIONS  xxix 


363.  Lateral  drainage  of  bladder  after  crescentric  approach   to  prostate 

gland 576 

364.  Appearance  of  wound  after  incision  for  hydrocele.     (Bryant.)   .         .  579 

365.  Infiltration    of    tunica,    scrotum    and    penis    following   operation    for 

varicocele 581 

366.  Dressing  after  circumcision 582 

367.  Chetwood's  two-way  urethral  nozzle.     (Keyes.) 585 

368.  Chetwood's  scissors  shut  off.     (Keyes.)  .......  585 

369.  Chetwood's  irrigator.     (Keyes.)       ........  586 

370.  Chetwood's  irrigator  in  use.     (Keyes.) 586 

371.  Dupuytren's  contraction.     Splint  for  dressing.     (Cheyne.)   .         .         .  590 

372.  Lateral   splint    for   holding   toe   after   operation    for   hallux   valgus. 

(Foote.) 591 

373.  Hallux    valgus.      Diagram     showing    principle     in     making     shoes. 

(Cheyne.) 592 

374.  Piece  of  gauze  arranged  to  obviate  tendency  to  recurrence  of  hallux 

valgus 593 

375.  Diagram  to  illustrate  "toe-post."      (Cheyne.) 593 

376.  Markedly   rigid   feet   up    in   corrected   position    in    circular   gypsum 

splints.      (Foote.) 594 

377.  Whitman's  spring  for  flat  feet.     (Cheyne.) 595 

37S.     Lateral  and  inferior  view  of  Hoffa's  foot  plate  for  flat-foot.     (Von 

Bergmann.) 595 

379.  Boots    for    flat-foot.     (Cheyne.)      . 596 

380.  Manipulation   to   overcome   recurrence   of   flat-foot   after   correction. 

(Foote.) 597 

381.  Sayre's     apparatus     for     use     after     tenotomy     of     tendo-Achillis. 

(Cheyne.)  .         . 598 

382.  Boot  for  use  after  tenotomy  of  tendo-Achillis.     (Cheyne.)  .         .  599 

383.  Apparatus  for  bow-legs.      (Dennis.) 601 

384.  Suspended  bracketed  plaster-of-Paris   splint.      (Bryant.)    .         .         .  604 

385.  Bracketed    suspended   plaster-of-Paris   splint   for   excision    of   ankle 

joint.     (Bryant.) 604 

3S6.     Bracketed    suspended   plaster- of- Paris    splint    for   excision    of    wrist 

joint.     (Bryant.)  . 605 

387.  Open  method  of  treating  amputation  wound 607 

388.  Amputation  wound  with  interrupted  sutures  and  tube  drainage  intro- 

duced      609 


389.  Amputation  wound  dressed,  stump  on  splint 609 

390.  Profile  view  of  rubber  foot 614 

391.  Spring  mattress  for  rubber  foot.              615 

392.  Position  of  rubber  foot  when  walking 615 

393.  Position  of  rubber  foot  on  inclined  plane 616 

394.  Appliance  for  instep  amputations 616 

395.  Appliance  for  instep  amputations  in  place     .         .         .         .         .         .617 

396.  Appliance  for  instep  amputations  in  use 617 

397.  Appliance  for  retracted  heels   following  tarsal   amputations      .         .  61S 

398.  Appliance  for  retracted  heel  following  tarsal  amputations  in  place  .  618 

399.  Appliance  with  annular  top  for  retracted  heel  following  tarsal  ampu- 

tations   619 


XXX 


LIST   OF   ILLUSTRATIONS 


FIGURE  « 

400.  Appliance  with  knee  joint  and  thigh  for  tarsal  amputations 

401.  Appliance  for  ankle-joint  amputations  . 

402.  Appliance  for  ankle-joint  amputations  in  place  . 

403.  Appliance  for  end-bearing  stumps  at  ankle  joint  . 

404.  Appliance  for  tapering  tibial  stump 

405.  Appliance  for  tapering  tibial  stumps     . 

406.  Appliance  for  short  tibial  stumps  .... 

407.  Appliance  for  short  tibial  stump  in  place     . 

408.  Mechanism  of  knee  joint  for  short  tibial  stumps 

409.  Knee   joint   in   place         . 

410.  Mechanism  of  appliance  in  knee-bearing  stumps  . 

411.  Appliance  for  knee-bearing  stumps         .         .    •     . 

412.  Appliance   for   knee -bearing   stump,   showing   degree 

tainable 

413.  Appliance  for  thigh  stump.     (Lateral  view.) 

414.  Appliance  for  thigh  stump.     (Posterior  view.) 

415.  Mechanism  of  knee  joint  in  appliance  for  thigh  stum 

416.  Appliance  for  thigh  stump.     Knee  in  full  extension 

417.  Appliance  for  thigh  stump.     Knee  in  partial  flexion 

418.  Appliance  for  thigh  stump.    Knee  in  full  flexion 

419.  Appliance  for  hip  amputation.     (Anterior  view.) 

420.  Appliance  for  hip  amputation.      (Posterior  view 

421.  Appliance   for   hip    amputation.     (Lateral    view. 

422.  Appliance  for  hip  amputation.     (Patient  sitting 

423.  Appliance  for  amputation  of  hand 
424..  Appliance  for  amputation  of  arm  . 

425.  Lateral  manipulation  of  patella 

426.  ParkhilPs  screws  in  situ.     (Bryant.) 

427.  Method  of  preparing  rubber  tissue  for  dressing  wounds 

428.  Rubber  tissue  prepared  for  application  to  wound 

429.  Fenestrated  rubber  tissue  applied  to  wound  . 


of   flexion    ob- 


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624 
625 
625 
626 
626 
627 
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627 
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628 
629 
632 
633 
637 
638 
638 


PREPARATORY  AND  AFTER  TREATMENT 
IN  OPERATIVE  CASES 

CHAPTEE    I 
GENERAL  CONSIDERATIONS 

Cases  in  which  operations  are  not  urgent — Recording  the  history — Office  ar- 
rangement— Bronchitis — Pulmonary  tuberculosis — Tuberculosis  of  glands, 
bones,  and  other  parts — Nephritis — Cardiac  and  arterial  disease — Rheuma- 
tism and  gout — Syphilis — Hemophilia — Alcohol — Tobacco — Morphin,  Co- 
cain,  etc. — Obesity — Diabetes — Training  of  Tolerance  for  Manipulation  of 
Cavities. 

CASES   IN   WHICH   OPERATIONS  ARE   NOT  URGENT 

The  practitioner  frequently  sees  cases  presenting  afflictions 
which  require  operative  procedure  for  relief,  but  in  which  the  con- 
dition will  allow  of  previous  systematic  preparation.  !STot  infre- 
quently a  careful  taking  of  the  history  and  a  detailed  general 
examination  will  discover  complications  which  in  no  wise  are 
consequential  to  the  condition  from  which  relief  is  sought,  and 
which  do  not  in  any  sense  stand  in  a  causative  relationship  to  it. 

If  the  operative  measures  are  postponed  until  the  coexisting 
pathological  condition  is  remedied,  or  at  least  modified,  so  as  to 
take  from  the  surgical  problem  factors  which  may  have  a  deter- 
mining influence  on  the  outcome  of  operative  efforts  at  relief,  the 
mortality  rate  of  major  operations  will  be  reduced,  and  the  period 
of  postoperative  disability  much  shortened.  Also,  patients  may 
escape  postoperative  complications  which  might  not  have  obtained 
had  due  consideration  been  shown  the  co-existing  disease. 

The  conditions  which  are  perhaps  the  most  important  factors 
worthy  of  consideration  in  this  connection  are  taken  up  under  a 
general  head,  as  indicated  in  the  .title  of  this  chapter. 

Surgical  operations  have  become  so  common  a  procedure  and 
are  now  so  universally  employed  for  relief  of  affliction,  that  it  is 
not  improbable  that  the  viewpoint  of  the  profession  has  produced 

1 


2  GENERAL   CONSIDERATIONS 

a  dilution  of  conservatism  which  is  to  be  deprecated.  It  is  cer- 
tain that  the  measures  submitted  here  are  wise  and  useful,  and 
have  been  of  signal  service  to  those  employing  them. 

RECORDING   THE    HISTORY 

In  well  equipped  institutions  devoted  to  the  care  of  the  sick 
and  injured,  a  systematic  history  of  each  patient  is  taken  and  a 
careful  examination  of  the  blood,  urine,  feces,  etc.,  is  made. 
The  results  of  these  examinations,  together  with  the  history, 
are  recorded  by  the  house  staff,  and  as  a  rule  form  a  valuable  ad- 
junct to  the  means  at  the  disposition  of  the  surgeon  of  arriving  at 
a  conclusion  as  to  the  diagnosis,  and  aid  much  in  determining 
upon  a  method  of  surgical  procedure  indicated  in  a  given  case. 

However,  a  patient  admitted  to  an  institution  for  the  purpose 
of  seeking  relief  by  operation  is  not  infrequently  in  a  mental 
state  which  renders  an  accurate  recital  of  the  history  a  doubtful 
matter,  yet  the  patient  would  be  very  apt  to  recite  the  facts 
more  accurately  to  his  physician,  with  whom  he  is  likely  to  have 
been  on  terms  of  more  or  less  intimacy. 

Patients  who  are  to  be  subjected  to  operation  in  their  homes, 
or  under  conditions  where  the  regime  of  a  large  hospital  is  not 
available,  are  entirely  in  the  hands  of  their  medical  advisers,  and 
the  surgeon  looks  to  them  for  full  information  as  to  the  conditions 
which  may  influence  his  own  actions. 

It  is  not  a  laborious  undertaking  to  inscribe  a  history  of  the 
case  and  file  it  in  a  convenient  place  for  reference.  The  useful- 
ness of  such  a  measure  will  appear  as  the  writer  progresses  with 
this  work,  but  it  is  perhaps  proper  to  suggest  here  a  simple  method 
by  which  the  history  of  a  case  may  be  conveniently  recorded  and 
be  readily  available  when  needed. 

A  convenient  method  of  making  records  for  office  use  and  for 
the  purpose  of  guiding  the  surgeon  is  shown  by  the  accompany- 
ing illustrations.  There  are  many  cabinets  for  the  filing  of  card 
records  in  the  market,  purchasable  at  moderate  cost.  These  cabi- 
nets may  be  located  in  a  convenient  place  and  the  cards  filed  alpha- 
betically. The  writer  uses  three  cards,  a  white  one  (Figs.  1  and 
2)  upon  which  the  general  history  is  written,  a  yellow  one  for  the 
urine   (Fig.   3),  and  a  blue  one   (Fig.  4)    for  the  pathological 


Name  Smith,   Anna  -0ata  Jan.  .2nd,  1908, 

Residence      JJ0.    1  G-— -■  Str. 

Age      46  Sex     F.  Cond.  M.  Nat.    U.    S.  Occup.   Housewife 

Family  Hist.  Father  died  of  apoplexy  at.  45;  mother  died  at  63,  from 
Bright's  disease. 

Ptev.  Hist.  Has  had  six  children,  the  first  at  21,  the  last  at  36,  all 
normal  labors.   Nursed  all  the  children.   Menopause  two 
years  ago.   Had  typhoid  at  16,  complicated  by  phlebitis  of 
.left  thigh..   Has  had  severe  attacks  of  headache  for  last 
four  years.   Attacks  last  a  day  or  two,  then  clear  up. 
Two  months  ago  noticed  a  lump  ia  left  breast,  while  bath- 
ing.  Lump  was  not  painful,  felt  hard  and  was  about  the 
size  of  an  English  walnut.   When  first  noticed  the  lump 

(Over)  could  be  freely  moved.   Paid  no  attention  to  it.   Since 


(.IBRAAY  BUREAU,  A3S0B9 


Fig.  1. — Front  View  of  History  Card  with  History. 


then  has  noticed  that  skin  became  attached  to  the  lump  and 
that  it  had  increased  to  the  size  of  goose-egg.       Has  not 
lost  flesh.       Lump  feels  a  little  tender  now.       Examination 
shows  a  mass  as  described  in  outer  upper  quadrant  of  left 
breast.         Nipple  not  retracted.        Gland  at  outer  edge  of 
pect.  major  enlarged.         No  other  gland  palpable.         Re- 
garded as  malignant,  probably  scirrhus.         Advised  excision 
of  breast. 

Jan.  12.  Removed  small  section  of  mass.  See'  report. 
Cephalic  vein  dilated,  probably  involvement  of  glands  on 
axillary  sheath. 


Fig.  2. — Reverse  Side  of  History  Card.     History  Continued. 
3  o 


Name    Smith,  Anna. 

, 

Date 

Jan. 

3,   1908. 

Quantity  (24  hours)    43   oz. 

Specific  C 

ravity 

1010 

Color  Light  amber 

Reaction 

Acid 

Sediment  Slight    floCCUlent 

deposit. 

Urea        .021  gr.  per  c.c. 

Indican      Slight 

Microscopic  Examination    A  considerable   number 

of 

granular 

and 

a  few 

hyaline 

casts. 

Albumin    A  small  amount. 

Suear      Negative* 

UBRAMv'auRtA* 

»saos 

Fig.  3. — History  Card  for  Recording  Result  of  Urinary  Examination. 


Name     Smith,  Anna 

Date 

Jan.. 

4, 

1908. 

Pathological  Report 

(a)  Blood  Examination     ShOWS 

simple  anemia* 

(b)  Miscellaneous  Matter  (Sputum 

Transudations,  Specimens, 

etc.) 

Specimen  from  tumor  of 

breast-— scirrhus  carcinoma. 

Fig.  4. — History  Card  for  Record  of  Pathological  Report. 
4 


RECORDING   THE   HISTORY  5 

record.  The  latter  is  an  exceedingly  useful  one  upon  which  may 
be  added  the  microscopical  findings  of  neoplasms,  exudates,  etc. 
On  the  reverse  side  of  the  blue  card  there  is  a  place  for  a  record 
of  autopsy. 

The  cards  suitable  for  a  certain  size  of  cabinet  are  readily  ob- 
tained in  the  market,  and  may  be  printed  either  as  indicated  here 
or  in  a  manner  best  suited  to  the  method  of  the  practitioner.  In 
this  way  the  effect  of  diet  and  medication  is  recorded,  and  when 
the  time  for  operation  arrives  much  valuable  data  is  available. 

It  would  be  too  cumbersome  and  unwieldy,  to  say  nothing  of 
the  time  used  by  a  busy  general  practitioner,  to  expect  that  a 
complete  history  will  be  kept  of  every  case  of  bronchitis  or  con- 
stipation which  comes  under  observation.  However,  the  plan 
offered  or  a  similar  one  should  be  used  in  cases  which  demand 
operative  relief,  or  in  those  which  require  repeated  visits  or  ex- 
aminations for  the  purpose  of  diagnosis. 

For  instance,  the  recording  of  the  circumference  of  the  neck 
in  a  case  of  goitre  and  subsequent  measurements  made  from  time 
to  time  will  show  the  ratio  of  the  increase  in  size  of  the  growth 
and  thus  the  element  of  error  in  this  regard  is  avoided. 

Farther  than  this,  a  systematic  method  of  recording  the  history 
of  cases  tends  to  develop  accuracy  in  the  observation  of  details, 
an  exceedingly  important  factor  in  differential  diagnoses. 

The  illustrations  show  memoranda  which  record  the  history  of 
a  case  of  carcinoma  of  the  breast,  Figs.  1  and  2  (Fig.  2  is  the 
reverse  side  of  Fig.  1)  show  little  of  value  in  the  accessory  history, 
except  perhaps  that  the  father's  death  from  apoplexy  at  the  age 
of  45  might  be  regarded  as  arousing  suspicion  of  inherited  syph- 
ilis, this  being,  however,  rendered  negative  by  the  fact  that  the 
patient  had  six  healthy  children.  The  headache  carries  out  an 
accord  with  the  urine  analysis  (Fig.  3).  The  fact  that  the 
cephalic  vein  became  dilated  soon  after  the  first  examination  of 
the  patient,  would  seem  to  justify  the  belief  that  considerable  in- 
volvement of  the  glands  about  the  axillary  vein  had  occurred  in 
the  interim,  which  called  for  immediate,  radical  operative  relief. 

The  urine  analysis  as  reported  (Fig.  3)  is  that  of  a  small 
granular  kidney  and  suggests  general  arterial  disease.  It  also 
calls  for  the  precautions  taken  up  under  these  heads  further  on 
(page  15).     There  was  nothing  in  the  patient's  history  beyond  the 


6  GENERAL  CONSIDERATIONS 

headaches  mentioned  which  might  have  suggested  the  existence  of 
nephritis,  and  indeed  these  might  have  been  dne  to  many  other 
causes.  However,  the  examination  of  the  nrine  established  a  rea- 
sonable causative  relationship.  The  bearing  that  discovery  of  the 
conditions  mentioned  has  on  the  kind  of  narcotic  to  be  adminis- 
tered at  the  operation,  is  also  an  important  one. 

The  fact  that  nephritis  exists  would,  too,  determine  the  tech- 
nic  of  the  operation  with  the  view  of  shortening  the  time  over 
which  the  surgical  manipulations  were  carried,  if  this  were  con- 
sistent with  achieving  the  intent. 

Fig.  4  shows  the  pathological  report  which,  as  already  stated, 
is  recorded  on  a  blue  card  to  facilitate  ready  identification  when 
filed  among  a  large  number  of  histories.  The  blood  examination 
need  not  be  recorded  in  detail.  The  conclusion  from  the  exami- 
nation may  simply  be  recorded  as  shown  in  the  illustration.  The 
simple  anemia  in  this  case  shows  that  there  may  have  been  al- 
ready some  modification  in  general  nutrition  as  the  outcome  of  the 
presence  of  the  affliction,  though  the  body  weight  is  not  reduced 
and  the  appearance  of  the  patient  has  not  undergone  any  mani- 
fest change.  The  report  of  the  microscopical  examination  shows 
the  tumor  to  be  a  scirrhous  carcinoma.  In  these  cases  the  prog- 
nosis, as  a  rule,  is  not  necessarily  unfavorable.  However,  balanc- 
ing this  against  the  fact  that  the  cephalic  vein  is  dilated  and  that 
this  means  pressure  on  the  axillary  vein,  the  prognosis  becomes 
less  favorable,  on  the  ground  that  the  glandular  involvement  is 
probably  considerable  in  extent  and  may  have  taken  on  a  form  of 
carcinomatous  proliferation,  the  character  of  which  is  more  malig- 
nant than  that  which  obtained  in  the  original  focus  of  disease. 

A  complete  history  of  this  kind,  though  not  carried  out  in 
great  detail,  makes  quite  possible  a  rational  conception  of  the 
entire  situation,  and  is  invaluable  to  the  attending  physician,  and 
especially  to  the  surgeon  who  may  not  have  an  opportunity  to 
elicit  the  facts  thus  furnished. 

OFFICE    ARRANGEMENT 

The  facility  with  which  examinations  are  made  and  wounds 
cared  for,  is  not  a  little  enhanced  by  the  apparatus  and  elasticity 
of  its  arrangement  at  the  disposition  of  the  practitioner.     For  the 


Fig.  5. — Office  Equipment. 


Fig.  6. — Office  Equipment 


GENERAL  CONSIDERATIONS 


general  practitioner  a  suitable  arrangement  of  examining  table, 
instrument  table,  instrument  closet,  and  chair  is  shown  in  Fig  5. 

The  appearance  of  the  office  is  not  altogether  a  question  of 
scenic  effect.  As  a  rule,  the  display  of  awe-inspiring  white  en- 
ameled furnishings  have  an  objectionable  effect  upon  timid  pa- 
tients and  the  arrangement  shown  is  less  liable  to  provoke  fear 
than  if  the  furnishings  were  those  of  the  enameled  steel  variety. 

However,  it  is  to  be  borne  in  mind  that  in  the  examination  of 
genito-urinary  cases  and,  indeed,  in  instances  where  lavage  of  sur- 
faces or  irrigation  of  cavities  is  necessary  either  as  a  part  of  an 
examination  or  in  the  after-treatment  of  operative  cases,  the  en- 
ameled steel  table  with  drainage  is  exceedingly  valuable  and  is 
easily  kept  clean. 

The  arrangement  in  Fig.  6  shows  an  enameled  outfit,  which, 
however,  is  less  desirable  than  the  outfit  shown  in  Fig.  7,  which 


Fig.  7. — Office  Equipment. 


permits  of  drainage  during  the  lavage  of  the  perineum,  etc.  Be- 
tween the  outfits  shown  in  Figs.  5  and  6  there  is  not  much  choice, 
except  as  far  as  the  question  of  whether  wooden  or  steel  furnish- 
ings are  used,  except  that  the  enameled  outfit  gives  the  impression 


OFFICE   ARRANGEMENT 


9 


of  being  more  cleanly,  which  perhaps  is  only  true  as  far  as  the 
table  is  concerned. 

Of  these  three  outfits  Fig.  5  is  recommended  for  the  office  of 
the  general  practitioner.  Fig.  7  shows  a  more  elaborate  outfit 
suitable  for  the  surgeon's  office.  The  Trendelenburg  posture  is 
useful  when  small  operations  under  local  anesthesia  are  performed 
in  the  office. 

In  each  instance  it  is  best  to  have  the  examining  chamber 


O  o, 

Con    s    ulting 


Room 


Kece  pti  on 


O 


Fig.  8. — A  Simple  form  of  Consulting 
and  Reception  Room.  The  Examin- 
ing table  in  the  consulting  room  is 
placed  conveniently  to  the  light,  which 
falls  on  the  back  of  the  operator 
as  he  sits  at  the  foot  of  the  table; 
this  corner  of  the  room  is  screened 
off.      (Kelly.) 


Fig.  9. — Arrangement  of  Examining 
Room  Separated  from  the  Consult- 
ing Room.  The  patient  arranges  the 
clothing  behind  the  curtain  indicated 
by  the  wavy  lines.     (Kelly.) 

separate  from  the  consulting  room  if  this  be  feasible.  In  the 
event  of  this  being  impracticable,  the  outfit  shown  in  Fig.  5  is 
perhaps  the  least  liable  to  arouse  annoyance  in  the  minds  of  timid 
patients  and  will  disturb  less  the  symmetrical  appearance  of  the 
practitioner's  office,  especially  if  he  be  compelled  to  spend  much 
of  his  time  there,  using  the  chamber  for  other  purposes. 

Kelly  suggests  the  arrangement  of  the  practitioner's  office  as 
shown  in  Figs.  8  and  9.     The  arrangement  in  Fig.  8  may  be  em- 


10  GENERAL   CONSIDERATIONS 

ployed  when  the  available  space  is  limited.  A  portion  of  the  con- 
sulting room  is  used  for  the  purpose,  and  the  outfit  shown  in  Fig. 
5  may  be  arranged  as  shown.  A  more  elaborate  arrangement  is 
shown  in  Fig.  9,  including  a  reception  room,  a  consulting  room, 
and  a  separate  examining  room.  The  toilet  arrangements  in  the 
examining  room  are  placed  at  one  end  and  behind  curtains.  The 
outfit  shown  in  Fig.  7  can  advantageously  be  used  with  this  ar- 
rangement of  space. 

BRONCHITIS 

Rollier  considers  the  existence  of  bronchitis  as  a  strongly  pre- 
disposing condition  favoring  postoperative  broncho-pneumonia. 
As  the  outcome  of  observation  extending  over  many  years  he  re- 
gards the  administration  of  creosotol  of  signal  benefit.  The  drug 
is  given  by  mouth  in  doses  reaching  1.00  mornings,  and  intro- 
duced into  the  rectum  together  with  peptonized  milk  in  doses  of 
2.00  at  night. 

The  habits  of  life  of  the  patient  should  be  regulated  with  a 
view  to  overcoming  the  condition  in  the  bronchi.  If  it  be  expe- 
dient a  sojourn  in  a  dry  climate  for  several  weeks  before  the 
operation  should  be  indulged  in.  The  excessive  use  of  tobacco 
should  be  controlled,  and  if  feasible,  smoking  should  be  entirely 
abstained  from.  During  an  attack  of  acute  bronchitis,  which  may 
be  regarded  as  infective  in  origin,  no  operation  involving  the  ad- 
ministration of  narcosis  by  the  air  passages  should  be  undertaken. 

In  cases  of  chronic  bronchitis,  potassium  iodid  should  be  ad- 
ministered for  a  week  before  the  operation  and  stopped  twenty- 
four  hours  before  beginning  the  narcosis,  on  the  ground  that  the 
agent  increases  the  secretion  of  the  respiratory  mucosa,  an  unde- 
sirable condition  as  regards  the  inhalation  of  narcotics.  It  is  best 
to  furnish  the  patient  with  a  saturated  solution  of  potassium 
iodid,  of  which  he  is  instructed  to  drop  five  drops  into  a  half 
tumbler  of  water  to  be  taken  three  times  daily  after  eating.  The 
dose  is  increased  three  drops  a  day  until  slight  iodism  is  produced. 
If  the  time  set  for  the  operation  arrives  before  iodism  is  estab- 
lished the  agent  is  withdrawn,  as  indicated  above.  If  sharp  iodism 
occurs  just  before  the  time  set  for  the  operation,  a  postponement 
of  the  surgical  procedure  for  twenty-four  hours  is  desirable.  In 
case  iodism  occurs  a  week  before  the  operation,  tbe  drug  is  with- 


PULMONARY   TUBERCULOSIS  11 

drawn  for  a  day  and  again  administered  in  doses  of  half  the 
quantity  taken  at  the  time  iodism  occurred,  and  this  dose  is  main- 
tained to  within  twenty-four  hours  before  the  beginning  of  the 
operation. 

PULMONARY    TUBERCULOSIS 

Patients  suffering  from  advanced  pulmonary  tuberculosis  are 
exceedingly  unfavorable  subjects  for  operation.  However,  per- 
sons with  a  slight  or  moderate  invasion  of  the  lung  by  a  tubercu- 
lous process  should  not  be  deprived  of  the  opportunity  for  relief 
from  afflictions  susceptible  of  relief  by  surgical  intervention. 

The  exhausting  effect  of  malignant  disease,  or  perchance  uri- 
nary calculus,  should  not  be  permitted  to  go  on  because  of  an  exist- 
ing pulmonary  tuberculosis.  It  should  be  mentioned  in  this  con- 
nection that  pulmonary  tuberculosis  of  itself  is  not  a  necessarily 
fatal  disease,  and  that  under  proper  care  and  management  re- 
covery takes  place  in  a  not  inconsiderable  number  of  cases.  The 
chief  factor  to  bear  in  mind  is  that  the  addition  of  mixed  infec- 
tion is  usually  the  determining  causative  factor  productive  of  a 
fatal  outcome.  In  cases  of  lung  tuberculosis  where  operation  is 
necessary,  beyond  the  usual  treatment  of  over  feeding,  additional 
precautions  should  be  taken  to  prevent  the  occurrence  of  an  added 
infection  of  the  lung,  chiefly  of  the  class  which  is  generally  desig- 
nated under  the  head  of  "  Grippe." 

Patients  thus  afflicted  should  be  carefully  protected  from  ex- 
posures on  the  ground  that  additional  tax  upon  the  heat  unit  crea- 
tors may  be  avoided.  The  indiscriminate  employment  of  the  so- 
called  fresh  air  treatment  should  be  avoided.  It  is  difficult  to  see 
how  placing  a  patient,  suffering  from  pulmonary  tuberculosis,  on 
a  fire-escape  and  allowing  the  chill  night  air  to  extract  his  calorics, 
is  going  to  be  of  aid  in  combating  the  invasion  of  an  exhausting 
infection.  It  is  probable  that  a  well  ventilated  room  is  less  apt 
to  be  the  habitat  of  pathogenic  bacteria  than  one  not  so  treated. 
However,  the  general  medical  laws  of  reason  and  judgment  must 
not  be  disregarded  in  favor  of  a  fad  which,  to  say  the  least,  is  not 
founded  on  generally  accepted  physiological  facts. 

There  are  two  general  factors  which  render  patients  suffering 
from  pulmonary  tuberculosis  unfavorable  subjects  for  operation. 
One  is  the  exhausting  effect  of  the  operation  itself  and  the  other 


12  GENERAL  CONSIDERATIONS 

the  pernicious  effects  which  the  administration  of  a  narcotic  by 
the  respiratory  tract  has  directly  upon  the  lung  tissue.  In  a  general 
way,  the  latter  is  perhaps  the  more  important  determining  factor. 

With  regard  to  the  former,  the  patient  should  be  fed  along  the 
lines  now  so  generally  understood  as  to  need  no  prolonged  discus- 
sion here.  Eggs,  milk,  meat,  and  these  in  frequently  repeated 
doses,  should  be  given.  The  over-feeding  should  be  maintained 
until  within  five  hours  of  the  operation  and  the  starvation  period 
curtailed  as  much  as  possible. 

Rectal  feeding  should  be  begun  immediately  after  the  opera- 
tion, indeed  before  the  patient  leaves  the  operating  table,  and  the 
various  measures  destined  to  allow  of  early  nourishing  carefully 
observed  (page  287). 

Creosote  should  be  given  by  the  mouth  for  a  week  or  more  be- 
fore the  operation,  preferably  in  a  keratin  coated  pill,  to  obviate 
gastric  disturbances,  and  the  patient  should  be  ordered  to  inhale 
vaporized  creosote  for  several  hours  daily  with  the  view  of  ren- 
dering less  liable  the  occurrence  of  a  complicating  infection  of  the 
lung,  rather  than  because  it  is  believed  that  these  measures  will 
benefit  the  tuberculous  process  in  the  lung  itself. 

-  Various  forms  of  vaporizers  are  on  the  market,  any  one  of 
which  will  serve  the  purpose.  In  the  event  of  none  of  these  being 
available,  the  creosote  may  be  mixed  with  alcohol  and  dropped 
on  a  sponge  fastened  in  the  apex  of  a  tin  funnel  and  then  held 
before  the  nose  and  mouth. 

Too  often  does  the  surgeon  see  cases  of  latent  pulmonary  tuber- 
culosis develop  an  acute  exacerbation  after  a  surgical  operation, 
which  carries  off  the  patient  in  a  short  time.  How  often  this  will 
be  avoided  by  taking  the  extra  precautions  here  mentioned,  it  is, 
of  course,  difficult  to  say.  However,  the  physician  who  gets  his 
case  ready  for  the  surgeon  might  well  consider  the  proposition 
from  this  aspect  and  perhaps  avoid  unfavorable  outcome  as  the 
result. 

TUBERCULOSIS   OF   GLANDS,   BONES,   AND    OTHER  PARTS 

Tuberculosis  of  glands,  bones,  and  other  parts  should  be  handled 
along  the  same  lines  as  indicated  in  connection  with  lung  tuber- 
culosis, though  the  added  danger  of  the  baneful  effect  of  the  nar- 


NEPHRITIS  13 

cotic  on  the  lung  tissue  does  not  enter  as  a  factor  here.  The  special 
precautions  to  be  taken  with  a  view  to  rendering  the  surface  of 
the  body  asceptic  when  operation  is  undertaken  for  bone  tubercu- 
losis which  has  broken  down,  will  be  taken  up  with  skin  steriliza- 
tion (page  51). 

NEPHRITIS 

Albuminuria  does  not  necessarily  mean  kidney  lesion.  The 
presence  of  casts  may  mean  kidney  disease,  but  the  kind  of  kidney 
disease  and  perhaps  its  extent  are  determined  by  a  complete  chem- 
ical, quantitative,  qualitative,  and  careful  microscopical  examina- 
tion of  the  urine.  It  is  not  improbable  that  the  evidence  of  the 
clinical  significance  of  kidney  lesion  is  to  an  extent  standardizable 
by  the  condition  of  the  heart,  blood  vessels,  and  the  liver.  The 
simple  presence  of  albumin  in  the  urine  does  not  call  for  especial 
measures  of  treatment. 

Kidney  disease  without  manifest  arterial  and  cardiac  disease 
calls  for  special  precautions  during  the  period  of  preparation  for 
operation.  Alcohol  should  be  absolutely  avoided,  bearing  in  mind, 
however,  the  precautions  in  this  regard  taken  up  under  alcohol 
(page  23).  It  may  be  said  here  that  the  tendency  toward  radi- 
calism in  this  connection  is  perhaps  more  justified  than  obtains 
when  nephritis  does  not  exist.'  The  additional  tax  upon  the  kidney 
parenchyma  in  eliminating  alcohol  seems  to  justify  this. 

The  aim  of  the  physician  should  be  to  render  as  light  as  pos- 
sible the  labor  of  the  kidney,  in  the  separation  and  elimination 
of  the  end  products  of  metabolism.  It  is  generally  believed  that 
the  kidney  is  most  largely  concerned  in  eliminating  the  end  prod- 
ucts of  proteid  waste  and  digestion.  The  diet,  therefore,  should 
contain  the  least  quantity  of  organic  nitrogenized  constituents  con- 
sistent with  the  general  health.  Meats  and  eggs  are  to  be  avoided. 
The  proteids  exist  in  most  starchy  foods,  and  probably  in  sufficient 
quantity  to  avoid  error  in  nutrition  which  might  occur  as  the  re- 
sult of  their  entire  withdrawal.  A  purely  milk  diet  would  be, 
logically,  of  perhaps  the  most  service  in  this  connection,  milk  con- 
taining comparatively  small  quantities  of  nitrogen.  However, 
some  license  should  be  given  the  patient  and  white  chicken  meat 
and  fish  allowed  once  daily. 

Large  quantities  of  water  should  be  partaken  of.     It  is  not 


14  GENERAL   CONSIDERATIONS 

improbable  that  the  washing  of  the  kidney  in  this  way  is  service- 
able, on  the  theory  that  the  effort  on  the  part  of  the  cell  lies  along 
the  lines  of  converting  an  end  product  of  metabolism  from  alkaline 
medium  into  an  acid  excretion.  It  would  seem  probable  that  the 
urea  and  other  soluble  constituents  of  the  urine  are  mechanically 
washed  out  of  the  kidney  in  this  way. 

The  kidney,  however,  is  not  the  only  organ  concerned  in  elimi- 
nating the  end  products  of  metabolism.  The  skin  and  intestines 
are  important  eliminating  organs,  and  the  labor  of  the  kidney  may 
be  greatly  lightened  by  using  these  vicarious  channels  of  elimina- 
tion during  the  period  of  preparation  for  operation.  The  adminis- 
tration of  pilocarpine,  steam  baths,  and  the  maintenance  of  the 
body  at  a  temperature  at  which  the  skin  acts  freely,  are  useful 
measures. 

Catharsis  and  colic  lavage  are  to  be  used  freely.  The  former 
is  perhaps  well  achieved  by .  the  administration  of  sodium  phos- 
phate in  hot  water  before  breakfast,  and  the  latter  employed  at 
night,  using  a  quart  or  more  of  normal  saline  solution  for  the  pur- 
pose. If  the  nephritis  be  a  part  of  general  arterial  and  cardiac 
disease,  a  judicious  mingling  of  the  rules  laid  down  in  each  par- 
ticular class  of  cases  is  to  be  employed.  The  proteids  should  be 
increased  to  lessen  the  work  of  the  digestive  organs  and  a  daily 
examination  of  the  urine  made  to  act  as  a  guide  for  the  variations 
in  amount  of  these  articles  of  diet.  Although  this  detail  is  some- 
what laborious,  it  is  well  to  bear  in  mind  that  the  condition  of  the 
patient  at  the  time  of  the  operation  in  this  regard  is  an  exceed- 
ingly important  and  perhaps  determining  factor.  The  conserva- 
tion of  a  diseased  organ  like  the  kidney  may  place  it  in  a  position 
to  take  care  of  the  end  products  of  ferments  entering  the  circula- 
tion as  the  outcome  of  reparative  process,  and  even  in  cases  where 
infection  does  not  take  place  the  presence  or  absence  of  these  bodies 
in  the  blood  may  be  regarded  as  a  predisposing  factor  toward 
infection. 

The  physician  should  give  the  patient  a  written  set  of  orders 
each  evening  to  govern  the  diet,  amount  of  water  to  be  taken,  time 
and  length  of  steam  bath,  temperature  of  the  room,  and  the  char- 
acter and  quantity  of  clothing  to  be  worn  in  the  house  and  when 
in  the  open  air. 

The  conclusions  in  these  regards,  the  physician  arrives  at  as 


CARDIAC   AND   ARTERIAL   DISEASES  15 

the  result  of  the  analysis  of  the  urine  made  that  day,  and  the 
variations  in  the  quantitative  analyses  shown  as  the  outcome  of 
the  regime  of  the  day  before.  It  is  true  that  persons  afflicted 
with  kidney  lesions  would  demur  at  this  radicalism  if  it  were 
extended  over  a  prolonged  period  of  time,  and  perhaps,  too,  the 
fact  that  diseased  kidneys  frequently  seem  to  have  no  determin- 
ing influence  on  the  general  health  of  patients  would  seem  to 
make  the  effort  unnecessary.  However,  during  the  period  of 
preparation  for  operation,  the  writer  regards  the  measures  indi- 
cated as  essential  and  admonishes  the  physician  to  see  to  their 
execution. 

Again,  the  evident  concern  for  the  patient  and  the  manifest 
interest  evinced  by  the  practitioner  in  the  effort  for  a  successful 
outcome  of  the  operation,  will  place  the  physician  in  a  more  de- 
sirable position  both  with  the  patient  and  his  colleague,  the  surgeon. 

It  is  not  infrequently  the  experience  of  the  surgeon  to  have 
sent  to  him  for  immediate  operation  a  case  which  has  to  be  de- 
layed while  the  preparations  stated  are  made.  This  involves  an 
ignominy  to  the  physician  which  should  be  avoided. 

CARDIAC   AND   ARTERIAL   DISEASES 

These  conditions  are  so  closely  allied  and  so  frequently  co- 
exist that  they  may  be  considered  together. 

In  preparing  for  operation  patients  who  suffer  from  either 
or  both  of  these  conditions,  the  aim  of  the  attendant  must  be  to 
lessen  the  labor  which  these  organs  are  called  upon  to  perform, 
rather  than  to  attempt  radical  curative  measures.  Cardiac  val- 
vular disease  with  compensatory  hypertrophy  of  heart  muscle,  the 
outcome  of  previous  endocarditis  of  rheumatic  origin  or  the  sequel 
of  an  acute  infectious  disease,  does  not  call  for  special  measures 
beyond  resting  the  heart  muscle  as  much  as  possible  and  giving 
the  patient  a  diet  which  will  tax  as  little  as  is  possible  the  cir- 
culation during  digestion. 

The  indiscriminate  administration  of  cardiac  stimulants  such 
as  digitalis  is  to  be  avoided.  The  pulse  rate  during  rest  and  after 
exertion  should  be  carefully  noted,  and  efforts  allowed  within  the 
range  indicated. 

If  there  be  compensatory  hypertrophy,  the  heart  should  not  be 


16  GENERAL   CONSIDERATIONS 

expected  to  do  additional  work  during  the  period  of  preparation 
for  operation,  though  absolute  confinement  to  bed  might,  on  the 
other  hand,  have  a  sufficiently  depressing  effect  upon  the  patient 
to  over-balance  the  beneficial  effect  of  the  conservation  of  the  vital 
forces  by  absolute  rest. 

The  handling  of  these  cases  requires  some  tact  and  consider- 
able ingenuity.  Most  practitioners  would  regard  systematic  exer- 
cise as  a  valuable  aid  in  bringing  the  patient's  general  tone  to  its 
most  useful  level.  However,  in  cases  of  cardiac  valvular  disease 
the  form  of  exercise  should  be  modified  so  as  to  stop  short  of 
giving  rise  to  dyspnea. 

Many  laymen  have  the  notion  that  exercise  in  the  form  of 
golf  or  horse-back  riding,  and  the  like,  would  be  of  service  in 
rendering  them  better  fitted  to  withstand  a  severe  strain  of  the 
so-called  vital  forces.  In  most  instances  this  is  true,  but  if  the 
physician  discovers  a  heart  lesion  during  the  preliminary  exami- 
nation it  is  his  duty  to  acquaint  the  patient  with  the  conditions 
and  advise  modification  of  mode  of  life  consistent  with  the  facts 
presented. 

The  taking  of  nourishment  is  influenced,  both  as  regards  quan- 
tity and  character  by  the  mental  state  of  the  patient,  and  if  it  be 
apparent  that  the  restrictions  with  respect  to  exercise  are  the 
cause  of  apprehension  or  mental  depression,  which  interferes  with 
nutrition,  a  drive  in  the  open  air  or  a  daily  walk  at  the  rate  of  two 
miles  an  hour  should  be  allowed,  both  of  these  to  be  so  timed  that 
the  usual  meal  is  taken  soon  after  a  period  of  rest,  which  should 
follow  the  exertion.  Fifteen  to  thirty  minutes  of  rest  is  sufficient 
for  the  purpose. 

Unnecessary  exertion  during  digestion  should  be  avoided.  The 
picture  presented  by  the  engorged  lacteals  and  veins  of  the  mesen- 
tery concerned  in  extracting  from  the  digestive  tract  the  nutritive 
constituents  of  articles  of  diet,  during  digestion,  when  animals 
are  subjected  to  celiotomy  at  this  period,  is  a  strong  appeal  in 
favor  of  conserving  the  energies  of  the  patient  in  this  class  of 
cases.  The  circulation,  of  which  the  heart  is  the  chief  vis  a  tergo 
should  not  be  additionally  taxed  as  the  result  of  physical  exertion 
at  this  time. 

It  is  perhaps  proper,  in  this  connection,  to  call  attention  to 
the  fact  that  the  human  animal  is  the  only  one  which  voluntarily 


CARDIAC   AND   ARTERIAL   DISEASES  17 

engages  in  physical  exertion  immediately  after  eating.  All  of  the 
lower  animals  repose  during  digestion,  a  teleological  example  it 
would  be  wTell  for  the  physician  to  have  his  patient  emulate,  es- 
pecially in  instances  where  the  circulatory  organs  have  undergone 
pathological  changes. 

In  this  class  of  cases,  too,  the  diet  should  consist  largely  of 
proteids,  which  leave  comparatively  little  residue  after  the  nutri- 
tive constituents  of  articles  of  diet  have  been  extracted  from  the 
ingesta,  and  which  do  not  severely  tax  the  organs  concerned  in 
furnishing  the  necessary  ferments  to  the  digestive  tract,  occupied 
in  converting  into  glucose  the  carbohydrates,  or  of  emulsifying 
the  fats  into  readily  absorbable  form. 

This,  of  course,  does  not  apply  to  the  class  of  cases  in  which 
nephritis  exists  as  a  part  of  a  general  arterial  disease.  However, 
the  question  of  administering  the  proteids  in  cases  of  nephritis  is 
taken  up  under  that  head  (page  13). 

If  the  heart  fiber  be  sufficiently  impaired  to  justify  the  use  of 
artificial  stimulation,  a  careful  record  of  the  medication  adminis- 
tered should  be  kept,  and  this  should  form  the  basis  of  the  conduct 
of  the  case  during,  and  immediately  after,  the  operation.  Then, 
too,  the  technic  of  the  actual  operation  may  be  varied  in  order 
to  meet  the  indications  during  the  procedure,  if  cognizance  be  taken 
of  the  degree  and  character  of  stimulation  employed  in  a  given 
case.  For  instance,  a  careful  repair  by  sewing  of  the  layers  of 
the  broad  ligament  after  pan-hysterectomy  might  be  omitted  as 
a  refinement  in  technic  which  is  not  essential  to  the  consum- 
mation of  the  intent  of  the  operation,  if  the  symptoms  presented 
by  the  patient  indicate  that  the  artificial  tone  of  the  heart  fiber, 
the  outcome  of  stimulation,  is  giving  evidence  of  feebleness.  In- 
deed, a  knowledge  of  the  exact  conditions  in  this  regard  may  de- 
cide the  surgeon's  technic  in  a  given  case  and  cause  him  to  abandon 
the  more  complex  method  of  procedure  for  one  less  desirable  but 
perhaps  equally  effective,  as  far  as  relief  is  concerned,  when  all  the 
conditions  are  taken  into  account. 

A  simple  test  with  regard  to  the  tone  of  the  cardiac  muscle 
fiber  is  one  suggested  by  Katzenstein.  Both  external  iliac  arteries 
are  compressed  for  from  two  to  five  minutes.  The  normal  heart 
does  not  accelerate  its  action  under  these  conditions,  but  if  there 
be   cardiac   insufficiency  the   pulse   rate  becomes   perceptibly   in- 


18  GENERAL   CONSIDERATIONS 

creased.  If  the  heart  muscle  is  insufficient,  the  blood  pressure 
is  lowered,  if  no  insufficiency  exists  it  rises.  Kocher  advises  the 
use  of  the  Riva-Roeci  apparatus  to  determine  the  blood  pressure. 

In  cases  of  varicose  condition  of  the  veins  of  the  lower  extremi- 
ties the  danger  of  thrombi  and  embolism  should  be  borne  in  mind. 
An  elastic  stocking  should  be  worn  during  the  day  and  the  legs 
elevated  while  the  patient  assumes  the  recumbent  position,  meas- 
ures which  should  be  employed  for  several  weeks  before  the 
operation. 

RHEUMATISM   AND    GOUT 

Beyond  the  endocardial  and  endarterial  changes  caused  by  these 
afflictions  the  employment  of  special  measures  is  called  for  when 
patients  thus  afflicted  are  about  to  be  subjected  to  operation.  The 
reduction  of  resistance  accompanying  all  operative  procedures  is 
liable  to  precipitate  an  outburst  of  rheumatic  inflammation  of 
the  various  serous  membranes  of  the  body.  It  is  not  uncommon 
for  persons  afflicted  with  the  so-called  rheumatic  or  gouty  diathesis 
to  have  an  attack  of  "  rheumatic  fever  "  immediately  after  a  major 
operation. 

Persons  afflicted  in  this  way  who  are  about  to  be  subjected  to 
operation  should  be  given  much  the  same  preparation  as  for  nephri- 
tis (page  13).  Beyond  this,  the  salicylates  and  colchicum  should 
be  given  for  a  week  or  more  preceding  the  operation.  A  useful 
method  is  to  combine  asperin  in  doses  of  ten  grains  with  colchi- 
cin,  which  are  administered  three  times  daily  after  eating.  Of 
course,  a  surgical  operation  during  an  acute  attack  of  either 
rheumatism  or  gout  is  only  justifiable  in  the  event  of  the  occur- 
rence of  some  grave  condition  which  would  justify  the  measure 
despite  the  added  dangers  as  the  result  of  the  complication. 

In  the  subacute  or  latent  forms  of  the  diseases  it  is  well  to 
combine  small  doses  of  iodid  of  potassium  with  the  salicylates 
and  colchicum.  The  dose  of  iodid  of  potassium  need  not  exceed 
five  grains  three  times  daily.  When  the  three  agents  are  given 
together  they  should  be  administered  in  solution,  and  well  diluted, 
perhaps  best  in  an  alkaline  water  and  taken  during  digestion. 

These  precautions  need  not  be  limited  to  cases  which  present 
more  or  less  indefinite  manifestations  at  the  time  the  operation 
is  decided  upon.     If  it  appear  in  the  history  of  the  case  that  the 


RHEUMATISM  AND   GOUT  10 

patient  has  had  rheumatism  or  gout,  and  especially  if  he  be  past 
the  meridian  of  life,  it  is  wise  to  take  measures  of  safety. 

The  writer  recalls  a  case  of  irreducible  hernia  which  had  be- 
come inflamed.  The  patient,  a  man  of  fifty-five,  was  subjected 
to  herniotomy,  which  was  successfully  done.  At  the  end  of  a  week 
meningitis  developed,  which,  in  view  of  the  simultaneous  involve- 
ment of  several  of  the  joints,  was  regarded  as  of  rheumatic  origin. 
Caffeine  salycilate  was  given  hypodermically,  together  with  other 
anti-rheumatic  treatment,  and  the  patient  ultimately  recovered. 
Later  it  was  ascertained  that  he  had  had  two  attacks  of  acute 
articular  rheumatism  during  the  ten  years  before,  and  had  had 
various  more  or  less  indefinite  manifestations  since  that  time.  It 
has  been  the  writer's  custom  to  use  the  precautions  referred  to 
in  cases  to  be  operated  upon  which  present  a  rheumatic  or  gouty 
history,  and  to  follow  the  operation  with  an  enema  containing 
a  drachm  of  sodium  salycilate,  which  may  be  combined  very  read- 
ily with  other  nutritive  or  remedial  agents  indicated  at  the  time 
for  other  reasons. 

In  cases  of  this  sort  an  endocarditis  is  an  exceedingly  menac- 
ing complication  and  should  be  given  due  consideration  in  in- 
stances in  which  cardiac  symptoms  are  manifest,  which  are  not 
in  accord  with  the  other  symptoms,  which  may  be  properly  re- 
garded as  logically  consequential  to  surgical  trauma.  This  is  also 
true  with  respect  to  pleurisy.  It  is  not  uncommon  to  have  patients 
who  have  been  subjected  to  operation  develop  pleurisy  several  days 
after  the  operation.  This  has.  been  ascribed  to  exposure  to  cold, 
the  narcotic  used,  and  various  other  causes.  In  a  not  inconsider- 
able number  of  cases,  close  questioning  will  reveal  a  history  of 
a  previous  attack  of  rheumatism,  and  the  diagnosis  clears  up. 

In  most  instances,  when  the  pain  and  dyspnea  first  appear, 
the  attendant  immediately  thinks  of  a  septic  embolus  and  sees 
visions  of  suppurative  pneumonia,  empyema,  general  sepsis,  and 
death.  Of  course  the  examination  of  the  blood  and  the  absence 
of  the  characteristic  febrile  movement  of  sepsis  contribute  much  to 
making  clear  the  diagnosis.  However,  if  it  be  known  that  the 
patient  has  already  had  rheumatism,  the  case  is  more  readily 
treated  and  a  reasonable  assurance  of  recovery  may  be  given.  The 
simultaneous  involvement  of  the  serosa  of  a  joint  or  several  joints 
may  lead  to  a  correct  conception  of  the  condition  presented,  but  this, 


20  GENERAL   CONSIDERATIONS 

too,  may  lead  the  attendant  to  arrive  at  the  fallacious  conclusion 
that  he  is  confronted  with  a  case  of  general  sepsis  with  pyemic 
metastases. 

SYPHILIS 

During  the  more  or  less  acute  manifestations  of  the  secondary 
stage,  or  during  the  time  of  the  presence  of  the  lesion  correspond- 
ing to  the  port  of  entrance  of  the  infection  and  the  secondary 
manifestation,  may  be  regarded  as  a  contra-indication  to  opera- 
tion, unless  the  indication  for  measures  of  relief  by  surgical  pro- 
cedure are  imperative  and  necessary  to  recovery.  The  double 
reason  for  this  lies  in  the  fact  that  the  surgical  trauma  would  not 
readily  repair  and,  too,  because  of  the  danger  of  communicating 
the  disease  to  the  operator  and  assistants. 

If  emergency  arises  during  the  periods  of  the  disease  men- 
tioned the  operation  should  be  preceded  by  thoroughly  mercu- 
riarizing  the  patient  immediately  before  and  after  the  operation. 
This  is  best  done  by  intramuscular  injections  of  mercury,  either 
gray  oil  ('Fournier)  or  some  one  of  the  preparations  of  mercuric 
salicylate,  bichlorid  or  cyanid  now  on  the  market. 

The  operator  and  assistants  should  take  especial  precautions 
to  avoid  contamination  and  the  operation  be  carried  on  under 
antisepsis  rather  than  asepsis. 

Irrigation  of  the  operative  wound  with  bichlorid  solution  dur- 
ing the  procedure  seems  a  rational  indulgence,  bearing  in  mind, 
of  course,  that  serous  membranes  are  exceedingly  subject  to  chem- 
ical irritation  and  that  solutions  of  moderate  strength  should  be 
used  in  the  peritoneum  and  on  joint  surfaces.  In  wounds  of  the 
extremities  and,  indeed,  in  bone  trauma  the  tolerance  for  mercury 
is  considerable.  If  the  case  be  one  which  gives  a  history  of  syphilis 
of  long  standing  and  the  operation  be  not  imperatively  indicated, 
the  administration  of  anti-syphilitic  medication  may  be  given  by 
the  mouth,  taking  the  precautions  with  regard  to  salivation  and 
gastro-intestinal  disturbances  usually  employed. 

It  is  not  to  be  assumed  that  because  a  case  has  had  no  mani- 
festations for  several  years  that  the  problem  may  be  disregarded. 
On  the  contrary,  cases  of  syphilis  which  have  apparently  com- 
pletely recovered  will  burst  out  into  distinct  syphilitic  manifesta- 
tions a  few  days  after  operation.     Theoretically  it  may  be  justifi- 


HEMOPHILIA  21 

able  to  assume  that  the  disease  has  been  under  control  and  that  the 
lessened  resistance,  which  is  the  outcome  of  the  operation,  has 
permitted  of  an  outburst.  The  writer  may,  in  this  connection, 
quote  a  case  of  a  woman  of  twenty-eight  who  was  subjected  to 
cholecystectomy  for  colelithaisis.  On  the  third  day  after  the 
operation  a  widely  spread  skin  lesion  developed,  which,  after  care- 
ful inquiry  respecting  the  husband's  and  her  own  history,  was 
determined  to  be  syphilitic.  The  eruption  cleared  up  very  readily 
under  appropriate  anti-syphilitic  treatment,  not  until,  however,  a 
small  ulceration  of  the  tongue  appeared.  The  latter  was  scraped 
and  the  presence  of  the  spirochete,  pallida  demonstrated. 

It  has  happened  in  the  experience  of  most  surgeons  that 
wounds  which  have  shown  no  evidence  of  infection  are  sluggish, 
do  not  heal,  and  the  stitches  cut  through  leave  a  pale  open  surface 
but  sparsely  covered  with  flabby  granulations.  These  cases,  if  they 
be  not  tuberculous,  will  usually  heal  very  readily  if  anti-syphilitic 
medication  be  administered,  and  the  attendant  faces  the  annoy- 
ance of  the  conviction  that,  had  his  patient  been  subjected  to  the 
precautionary  measures  indicated,  this  might  have  been  avoided. 

Wounds  which  do  not  heal  promptly  and  are  regarded  as  re- 
tarded by  the  syphilitic  condition  should  be  frequently  cleansed 
with  solutions  of  corrosive  sublimate,  and  after  the  lavage  the 
wound  and  contiguous  skin  dried,  using  ether  for  the  purpose, 
and  the  surface  of  the  traumatised  part  covered  with  the  ordinary 
mercurial  ointment. 

At  each  dressing  the  residual  ointment  is  removed  with  ether, 
the  wound  lavaged  with  corrosive  sublimate  solution,  and  again 
covered  with  the  ointment.  This  should  be  repeated  every  two 
days,  and  will  be  found  to  cause  healing  to  take  place  quite  rapidly. 

HEMOPHILIA 

Hemophilia  is  an  affliction  which  is  probably  attended  with 
some  abnormality  in  the  structure  of  the  blood  vessels  which  ren- 
ders them  more  liable  to  rupture,  in  addition  to  the  absence,  or  at 
least  modification,  of  the  so-called  fibrin  ferment  in  the  blood. 

If  the  peculiar  diathesis  be  recognized  before  surgical  trauma 
is  inflicted,  early  measures  should  be  taken  to  increase  the  pa- 
tient's general  condition,  with  a  view  to  improving  the  arterial 


22  GENERAL  CONSIDERATIONS 

tone.  How  much  exercise  and  proper  nourishment  will  contrib- 
ute to  this,  it  is,  of  course,  difficult  to  say.  However,  an  effort  in 
this  direction  should  be  made  and  a  regime  initiated  with  this  in 
view.  Bleeders  should  never  be  subjected  to  operative  procedure, 
except  when  it  would  appear  that  the  risks  are  justified  in  making 
the  effort,  in  view  of  the  character  of  the  affliction  for  which  the 
operation  is  undertaken.  Considerable  effort  has  been  made  to 
modify  the  conditions  by  administering  in  these  cases  various  sub- 
stances, with  a  view  to  increasing  the  coagulability  of  the  blood, 
at  least  for  a  sufficient  period  of  time  to  permit  of  operative  work 
and  subsequent  healing.  Most  of  these,  like  ergot  and  lead  ace- 
tate, have  proven  of  little  value. 

Thyroid  extract  seems  to  have  been  of  considerable  service. 
Fuller  and  Taylor  report  successful  results  in  operations  on  bleed- 
ers in  which  this  agent  has  been  administered  before  and  after 
the  operation.  Taylor  s  work  would  seem  to  show  that  normal 
blood  is  not  influenced  as  regards  coagulability  by  the  extract,  and 
that  it  acts  upon  the  blood  of  the  bleeder  which  seems  to  be  defi- 
cient in  so-called  fibrin  ferment. 
.  In  suspected  or  recognized  hemophilia,  if  feasible,  the  blood 
should  be  tested  and  the  time  required  for  coagulation  noted.  The 
extract  is  then  administered  in  doses  of  from  three  to  five  grains 
three  times  daily  after  eating,  and  at  the  end  of  forty-eight  hours 
the  blood  again  tested,  when  a  diminution  of  time  required  for 
coagulation  to  take  place  should  show  an  increased  rapidity  of 
50  per  cent. 

The  tests  are  cumbersome  and  difficult  to  manage.  Taylor 
used  W 'right's  method. 

It  is,  of  course,  not  feasible  to  subject  cases  of  hemophilia  to 
the  proper  chemical  test  required  to  prove  the  efficiency  of  the 
thyroid  extract,  in  each  instance,  especially  as  the  practitioner  is 
not  in  a  position  to  make  the  necessary  test,  because  of  lack  of 
particular  training  in  this  department.  However,  it  would  seem 
to  be  proper  to  administer  the  agent  in  cases  of  hemophilia,  with- 
out recourse  to  the  test  in  a  given  instance,  accepting,  as  indeed  we 
all  do,  the  outcome  of  the  investigations  of  reputable  laboratory 
workers. 

Thyroid  extract  is  liable  to  give  rise  to  cardiac  disturbances, 
and  the  dosage  should  be  regulated  in  accord  with  the  manifesta- 


ALCOHOL  23 

tions  in  this  regard.  The  administration  of  the  extract  need  not 
extend  over  a  longer  period  of  time  than  is  included  in  a  week 
before  and  a  week  after  the  operation. 

In  cases  of  jaundice  and  allied  conditions  which  favor  persist- 
ence of  bleeding  following  surgical  trauma,  the  extract  has  been 
found  of  service  in  controlling  the  hemorrhage.  (See  Obesity, 
page  31). 

Calcium  Chlorid  has  been  used  for  the  purpose,  eighty  grains 
being  administered  in  divided  doses  daily  for  two  days  before  the 
operation.  The  Mayos  have  used  this  agent  in  cases  of  severe 
jaundice.  They  do  not  regard  the  time  tests  of  the  coagulability 
of  the  blood  as  reliable. 

Gelatin.  Hare  recommends  the  administration  of  gelatin  to 
control  the  hemorrhage,  using  the  following  formula  for  the  pur- 
pose: 

Gelatin    

Sodii    Chloric! aa  10.0 

Aquae  dest 1,000  c.c. 

The  mixture  is  sterilized  by  heat  and  60  c.c.  are  injected  into 
the  buttock.  This  is  increased  to  120  c.c.  if  repetition  is  necessary. 
Usually  two  injections  are  used.  Gelatin  has  been  used  more 
largely  to  control  oozing  after  operation.  It  might  be  rational  to 
use  the  thyroid  extract  as  a  preparatory  measure,  and,  if  oozing 
occur  after  the  operation  the  gelatin  injections  may  be  used. 
Hare  regards  the  mixture  of  use  applied  locally  to  check  oozing. 

ALCOHOL 

There  can  be  no  doubt  that  from  a  scientific  standpoint  the 
human  animal  is  better  off  without  the  use  of  alcohol  in  any  form. 
It  is  also  probably  true  that  the  moderate  use  of  alcohol  does  no 
great  harm.  It  is  exceedingly  probable  that  the  use  of  grape  al- 
cohol is  less  harmful  than  that  of  grain  alcohol.  It  is,  however, 
also  true  that  the  vast  majority  of  people  use  alcohol  to  varying 
extent  and  in  varying  amounts.  The  physician  is  confronted  by  a 
clinical  fact. 

It  is  not  the  purpose  of  the  writer  to  enter  into  the  discussion 
of  the  place  alcohol  occupies  in  the  treatment  of  wasting  diseases 


24  GENERAL  CONSIDERATIONS 

or  prolonged  febrile  movement,  as  a  discussion  of  this  sort  does 
not  belong  here.  It  is,  however,  proper  that  the  matter  be  taken 
up  in  its  connection  with  the  preparation  of  chronic  alcoholics  for 
severe  operations. 

If  Bunge  is  right  that  a  normal  individual  weighing  140 
pounds  can  oxidize  two  ounces  of  alcohol  in  twenty-four  hours, 
almost  the  entire  human  race  may  be  regarded  as  chronic  alco- 
holics, for  most  men  take  more  than  two  ounces  of  alcohol  in  the 
day.  Two  ounces  of  alcohol  is  equivalent  to  four  ounces  of 
brandy,  and  about  the  same  or  a  little  greater  amount  of  whisky. 
Most  Americans  take  an  ounce  and  a  half  of  whisky  at  a  drink. 
If  three  drinks  of  whisky  in  the  day  be  the  basis  of  what  may  be 
regarded  as  not  excessive,  one  gets  a  pretty  good  standard  for  a 
working  basis.  It  is  a  simple  matter  to  apply  this  to  wines  and 
beers.  Average  amount  of  alcohol  in  brandy,  50  per  cent. ; 
whisky,  40  per  cent. ;  beer,  4  per  cent. ;  claret,  8  per  cent. ;  white 
wine,  10  per  cent. ;  champagne,  10  per  cent. 

Given  a  man  of  forty-five  or  more  who  has  habitually  taken 
a  whisky  and  soda  with  his  lunch,  a  cocktail  or  two  before  dinner 
and  a  light  wine  with  his  dinner,  and  possibly  the  equivalent  of 
two  drinks  of  whisky  during  the  evening,  one  must  regard  him  as 
a  chronic  alcoholic,  and  he  undoubtedly  is.  If  this  man  is  de- 
prived of  alcohol  as  a  matter  of  policy  he  probably  would  not  re- 
gard himself  subjected  to  great  hardship,  and,  beyond  a  more  or 
less  indefinite  discomfort  together  with  a  certain  irritability  of 
temper  which  he  does  not  associate  with  the  real  cause,  no  symp- 
toms would  develop.  But  let  the  conditions  arise  making  neces- 
sary a  severe  surgical  operation,  and  the  symptoms  arising  from 
the  withdrawal  of  alcohol,  added  to  the  natural  feeling  of  appre- 
hension attendant  upon  the  contemplation  of  a  severe  ordeal  and 
the  withdrawal  of  alcohol,  become  a  question  of  considerable 
moment. 

The  physician  has  no  right  to  act  the  part  of  the  social  re- 
former in  this  class  of  cases.  The  mental  state  of  a  patient 
about  to  be  subjected  to  a  severe  surgical  operation  is  at  best  a 
much  disturbed  one.  The  symptoms  attendant  upon  the  with- 
drawal of  alcohol  are  closely  allied  to  the  natural  state  of  mind 
of  the  patient,  i.e.,  irritability,  insomnia,  and  apprehension  out  of 
proportion  to  the  conditions  presented,  and  this  should  be  avoided 


ALCOHOL  25 

if  feasible.  It  is  wiser  for  the  physician  to  take  charge  of  the 
administration  of  alcohol  himself,  adjusting  the  quantity  and 
character  of  the  beverage  to  meet  the  indications. 

It  is  not  sufficient  to  lay  down  a  general  rule  in  this  regard. 
Inquiry  should  be  made  as  to  the  patient's  habits,  and  if  he  is 
made  to  understand  that  the  detail  is  entered  into  for  scientific 
reasons,  and  that  no  humiliation  is  involved  to  him,  the  occur- 
rence of  dangerous  complications  after  operative  procedure,  the 
outcome  of  deceit  or  false  timidity  may  be  avoided. 

If  there  be  sufficient  time  between  the  making  of  the  diag- 
nosis and  the  operation,  an  effort  should  be  made  to  have  the  pa- 
tient entirely  free  from  the  use  of  alcohol  at  the  time  of  the  oper- 
ation, but  if  this  be  not  feasible,  as  shown  by  the  symptoms  pre- 
sented, alcohol  should  be  given  up  to  the  day  of  the  operation, 
and  if  necessary  introduced  into  the  rectum  together  with  other 
remedial  agents  in  a  manner  which  will  be  taken  up  under  the 
head  of  rectal  alimentation. 

Patients  possessed  of  naturally  great  firmness  of  character, 
but  who  use  alcohol  as  the  result  of  congeniality,  a  part  of  a 
metropolitan  life,  are  apt  to  take  it  upon  themselves  to  suddenly 
stop  the  use  of  alcohol  because  of  the  general  instructions  given 
by  the  physician  that  alcohol  is  inimical  to  health.  This  sacrifice 
should  not  be  blindly  encouraged.  The  patient  himself  is  not  in 
position  to  judge  of  the  matter. 

Careful  inquiry  should  be  made  in  this  connection  and  the 
patient  advised  just  how  much  alcohol  and  in  what  form  it 
should  be  taken.  The  patient  then  considers  the  use  of  alcohol 
as  a  medication,  and  its  proper  and  physiological  use  will  not  be 
regarded  as  intended  to  produce  an  artificial  complacency  during 
a  severe  trial  of  fortitude,  a  proposition  a  well-balanced  man  is 
likely  to  shrink  from,  perchance  to  his  own  detriment.  In  these 
cases  it  is  best  to  reduce  the  amount  of  alcohol  to  two  ounces  in 
twenty-four  hours  and  control  the  increase  or  decrease  of  dosage 
as  meets  the  indications. 

If  brandy  or  whisky  is  used  it  should  be  largely  diluted.  The 
salts  in  vichy  water  and  similar  waters  separate  the  small  quan- 
tity of  resin  in  distilled  beverages,  and  it  is  best  to  use  carbonated 
or  still  plain  water  as  a  diluent.  In  persons  who  use  large  quan- 
tities of  alcohol  a  more  stringent  policy  should  be  pursued. 


26  GENERAL  CONSIDERATIONS 

It  has  been  the  experience  of  all  surgeons  to  see  delirium 
tremens,  and,  indeed,  meningitis  alcoholica,  develop  after  opera- 
tion on  patients  whom  the  surgeon  had  had  no  idea  were  alcoholic. 
Had  this  been  taken  into  consideration  and  the  case  treated  along 
the  lines  stated  above,  this  might  have  been  avoided.  Among 
postoperative  complications  which  are  in  no  wise  consequential 
to  the  procedure,  may  be  included  pneumonitis  and  infection  of 
the  superficial  wound ;  more  rarely  infection  of  the  deep  wound. 
Both  these  may  be  regarded  as  the  result  of  lessened  resistance, 
in  part  the  outcome  of  the  complete  withdrawal  of  alcohol. 

When  a  patient  who  consumes  large  quantities  of  alcohol  is 
about  to  be  subjected  to  operative  procedure  he  should  be  placed 
under  the  care  of  a  competent  nurse  for  several  days,  and,  if  fea- 
sible, for  a  week.  Alcohol  should  be  given  as  indicated  above,  and 
this  supplemented  with  the  bromides  and  chloral  at  night  and  sys- 
tematic exercise  and  bathing  during  the  day.  It  should  not  re- 
quire more  than  a  week  to  reduce  the  quantity  of  alcohol  neces- 
sary to  prevent  manifestation  dependent  upon  its  withdrawal. 

The  diet  should  be  light  and  nutritious,  consisting  mainly  of 
eggs,  milk,  lean  meat,  stale  bread,  and  fresh  vegetables.  An  exces- 
sive amount  of  carbohydrates  should  be  avoided  on  the  ground 
that  the  glycogenic  function  of  the  liver  should  not  be  severely 
taxed,  having  been  concerned  in  wrestling  with  the  end  product 
of  this  class  of  substance  for  so  long  a  period  of  time.  All  the 
eliminatory  organs  should  be  used  with  a  view  to  lessening  the 
burden  of  metabolism,  the  skin,  the  kidneys,  and  the  intestinal 
canal.  This  is  readily  accomplished  by  steam  baths,  massage, 
the  drinking  of  large  quantities  of  water,  and  lavage  of  the  colon. 

In  advising  the  use  of  these  measures,  the  physician  must 
state  to  the  patient  the  hour  at  which  the  steam  bath  is  to  be 
taken,  the  quantity  of  water  to  be  partaken  of  in  twenty-four 
hours,  and  the  time  at  which  the  colic  lavage  should  be  made. 
The  time  the  patient  is  to  be  in  the  steam  bath  should  be  advised ; 
the  kind  of  steam  bath  also. 

If  it  be  convenient  of  course  the  public  Turkish  bath  may  be 
used,  but,  if  this  be  not  feasible  for  any  reason,  one  of  the  appa- 
ratuses on  the  market  may  be  employed  in  the  patient's  house. 

It  is  probable  that  about  fifty  ounces  of  water  should  be  taken, 
beginning  with  a  glass  of  hot  water  before  breakfast.     This  should 


ALCOHOL  27 

have  a  pinch  of  salt  added  to  it.  Most  men  are  habituated  to 
emptying  the  bowel  immediately  after  breakfast,  and  this  time 
should  be  devoted  to  the  colic  lavage.  The  steam  bath,  and  sub- 
sequent massage  should  be  given  at  five  o'clock  in  the  afternoon, 
preferably  after  the  patient  has  taken  a  walk  or  drive  in  the  open 
air.  He  should  be  permitted  to  lie  down  for  an  hour  after  the 
bath,  but  should  not  be  encouraged  to  sleep,  so  that  he  might  not 
become  wakeful  after  dinner. 

The  time  could  be  well  taken  up  with  perusal  of  light  and 
amusing  literature.  After  dinner  it  is  best  to  allow  the  patient 
to  play  cards  or  attend  some  place  of  amusement  if  the  conditions 
permit.  Cheerful  surroundings  are  a  valuable  adjunct  in  these 
cases.  If  insomnia  occurs  recourse  to  hypnotics  need  not  be 
taken  at  once.  If  feasible,  an  attendant  or  member  of  the  family 
should  stay  in  the  room  with  the  patient,  and  after  he  has  retired 
read  to  him  or  engage  him  in  conversation  on  any  subject  other 
than  his  health  or  the  "  curse  of  rum."  Under  no  circumstances 
should  the  patient  be  allowed  to  go  to  bed  with  the  room  darkened 
and  morgue-like  silence  maintained.  The  notion  that  the  patient 
can  force  himself  to  sleep  is  a  fallacy.  On  the  contrary,  as  soon 
as  it  is  manifest  that  the  patient  is  restless  and  irritable,  his  at- 
tention should  be  engaged  in  other  matters  and  ultimately  a  hyp- 
notic administered  as  a  last  resort,  if  these  measures  fail  in  their 
purpose. 

As  to  the  mode  of  administration  of  alcohol,  a  light  wine 
taken  with  meals  is  of  course  the  least  harmful  method  of  use. 
However,  much  will  depend  upon  the  previous  habits  of  the  pa- 
tient. It  is  a  singular  fact  that  grain  alcohol  drinkers  have  a 
repugnance  for  grape  alcohol,  and  if  grape  alcohol  be  given  a 
grain  alcohol  drinker,  he  will  get  its  physiological  effects  and  re- 
gard himself  as  cured  of  his  alcoholic  appetite  because  he  no 
longer  needs  grain  alcohol.  All  alcoholic  beverages  should  be 
given  well  diluted  and  during  gastric  digestion. 

Alcohol  should  not  be  given  before  meals  for  obvious  reasons, 
but  it  is  to  be  borne  in  mind  that  the  aim  in  the  class  of  cases 
under  consideration  is  to  place  the  patient  under  the  most  favor- 
able possible  conditions  to  withstand  a  surgical  operation,  and  if 
the  withholding  of  alcohol  at  times  to  which  the  patient  is  habitu- 
ated is  going  to  increase  the  symptoms  related  above,  a  fair  com- 


28  GENERAL  CONSIDERATIONS 

promise  would  be  to  allow  the  administration  of  alcohol  before 
meals,  well  diluted  and  together  with  an  "  apertiff,"  like  anchovy 
or  caviar. 

If  the  operation  becomes  necessary  before  the  patient  is  en- 
tirely weaned  from  the  use  of  alcohol,  or  if  an  operation  becomes 
imperative  in  a  patient  who  is  alcoholic,  alcohol  should  not  be 
given  by  the  mouth  for  five  to  six  hours  before  the  operation.  In 
these  cases  an  enema  consisting  of  eight  ounces  of  peptonized 
milk  (cold  process),  forty  grains  of  sodium  bromid,  and  thirty 
grains  of  chloral  hydrate,  together  with  two  ounces  of  brandy, 
should  be  administered  two  hours  before  the  operation,  and  this 
should  be  repeated  three  hours  after  the  operation,  the  latter  to 
be  again  repeated  in  case  vomiting  be  a  marked  after  effect  and 
oral  administration  of  alcohol  thus  made  impossible. 

The  subsequent  administration  and  dosage  of  alcohol  are  con- 
trolled by  the  symptoms  manifested  later  on.  As  a  rule,  alcohol 
will  not  be  indicated  for  more  than  three  days  after  the  opera- 
tion, and  indeed  it  is  observed  in  hospital  practice  that  patients 
who  were  markedly  alcoholic  at  the  time  of  admission  to  the  hos- 
pital convalesce  and  recover  without  the  need  of  alcohol,  if  the 
the  case  has  been  rationally  treated  during  the  period  of  time 
mentioned. 

TOBACCO 

Much  of  what  has  been  said  of  alcohol  may  be  applied  to  to- 
bacco. While  a  discussion  regarding  alcohol  is  not  strictly  limit- 
able  to  the  male  sex,  it  may  be  said  that  women,  as  a  rule,  are  not 
alcoholics  and  still  less  users  of  tobacco.  It  is,  however,  true  that 
most  male  adults  use  tobacco  in  some  form.  Most  commonly  the 
tobacco  is  smoked. 

Here,  again,  no  discussion  of  the  moral  or  pathological  effect 
of  the  use  of  tobacco  will  be  entered  into.  It  is  sufficient  to  as- 
sume that  the  patient  smokes  or  uses  tobacco,  and  to  consider  what 
influence  indulgence  of  the  sort  has  on  the  mental  and  physical 
condition  of  the  patient  in  its  bearing  on  an  imminent  operative 
procedure. 

It  may  be  said  that  tobacco  has  a  disturbing  influence  on  the 
circulation,  giving  rise  to  what  is  known  as  the  tobacco  heart. 
Whether  this  is  the  outcome  of  an  effect  on  the  cardiac  centers  or 


TOBACCO  29 

on  the  muscle  fiber  of  the  heart  itself  makes  no  difference  as  far 
as  its  bearing  in  these  cases  is  concerned.  It  is  to  be  borne  in 
mind  that  withdrawal  of  tobacco  is  accompanied  by  tumultuous 
heart  action  together  with  certain  symptoms  associated  with  func- 
tional disturbances  of  the  nervous  system,  such  as  restlessness, 
apprehension,  irritability,  and  insomnia,  much  the  same  group  of 
symptoms  applying  to  alcohol.  Here,  again,  the  attendant  must 
exercise  rational  judgment  in  advising  the  patient,  bearing  in 
mind  that  it  is  best  to  have  the  patient  entirely  free  from  the  use 
of  tobacco  at  the  time  of  the  operation,  but  if  this  be  not  feasible 
without  great  hardship  to  the  patient,  conservatism  should  be  ex- 
ercised and  tobacco  allowed  in  sufficient  quantity  to  control  the 
symptoms. 

A  mild  Turkish  tobacco  or  a  carefully  "  cured  "  American  to- 
bacco should  be  used.  However,  if  the  patient  be  habituated  to 
the  flavor  of  Havana  tobacco,  and  it  appear  that  he  craves  for  the 
subduing  effect  of  this  particular  brand,  it  should  be  allowed  in 
as  moderate  a  quantity  as  possible.  It  is  confusing  to  the  surgeon 
to  standardize  the  import  of  pulse  rate  in  patients  who  have  the 
tachycardia,  which  is  the  outcome  of  the  sudden  withdrawal  of 
tobacco,  and  this  should  be  taken  into  consideration  in  arriving 
at  a  conclusion  as  to  the  significance  of  circulatory  disturbances 
during  operations,  which  may  be  fallaciously  ascribed  to  impend- 
ing shock  or  to  overdose  of  narcotic.  The  anesthetist,  too,  would 
have  one  disturbing  factor  removed  if  conversant  with  the  con- 
ditions in  this  regard. 

During  the  after-treatment  of  a  surgical  case  this  is  a  consid- 
eration of  some  import.  More  especially  if  there  be  a  dispropor- 
tion in  pulse  rate  to  number  of  respirations,  and  if  the  possibility 
of  this  being  the  outcome  of  the  withdrawal  of  tobacco  be  not  taken 
into  account  it  might  be  erroneously  considered  as  indicative  of 
infection. 

During  convalescence  the  bearing  which  the  use  of  tobacco 
may  have  on  quick  recovery  is  not  a  minor  factor.  There  can  be 
no  doubt  that  reaction  from  severe  surgical  operations  is  to  some 
extent,  at  least,  influenced  by  the  mental  status  of  the  patient,  and 
if  a  man  of  sixty  who  has  had  an  amputation  done  for  gangrene 
of  the  leg  is  permitted  to  sit  on  a  veranda  and  smoke,  he  will  con- 
valesce more  rapidly,  provided  he  has  been  habituated  to  the  use 


30  GENERAL  CONSIDERATIONS 

of  tobacco.  It  is  difficult  to  see  how  smoking  can  possibly  have 
any  effect  upon  the  genesis  of  reparative  processes,  but  if  the 
general  wide  principle  be  borne  in  mind  that  the  elements  from 
which  the  cell  makes  its  component  parts  are  derived  from  the 
ingesta  which  enters  the  gastro-intestinal  canal,  and  that  patients 
will  take  more  nourishment  under  the  conditions  mentioned,  we 
have  the  rationale  of  the  proposition  made  clear. 

MORPHIN,   COCAIN,  ETC. 

Morphinism  and  the  use  of  allied  substances  is  not  widely  dis- 
tributed, yet  is  sufficiently  frequent  a  condition  to  be  taken  into 
consideration. 

Patients  who  use  narcotics  or  anodynes  are  not  good  subjects 
for  operative  manipulation.  However,  surgical  interference  at 
times  becomes  necessary  with  this  class  of  patients,  and  the  condi- 
tions must  be  given  due  consideration.  The  physician  has  here  to 
deal  with  a  more  grave  and  more  distinctly  determining  compli- 
cation than  obtains  with  either  alcohol  or  tobacco. 

Patients  habituated  to  the  use  of  opium  or  other  narcotics  and 
anodynes  require  prolonged  treatment  to  effect  a  cure,  and  present 
more  acute  symptoms  when  the  drug  is  withdrawn  than  obtains 
with  the  agents  mentioned. 

Much  depends  upon  the  quantity  taken  daily  and  the  reason 
for  the  indulgence.  If  the  drug  be  taken  to  relieve  pain,  the  re- 
sult of  the  condition  for  which  the  operation  is  undertaken,  the 
drug  need  not  be  withdrawn  and  only  controlled  as  to  amount  and 
perhaps  mode  of  administration,  the  relief  of  the  affliction  by  the 
operative  measure,  rendering  permanent  withdrawal  of  the  drug 
a  comparatively  easy  method.  If  the  patient  use  the  drug  simply 
as  the  outcome  of  a  perverted  appetite,  an  effort  should  be  made 
to  effect  a  cure  before  the  operation.  Although  the  writer  feels 
that  efforts  of  this  sort  are  crowned  only  rarely  with  definite  and 
lasting  success.  The  patient  should  be  confined  under  observation 
and  the  dosage  of  the  drug  gradually  reduced,  and  if  possible  the 
patient  should  be  entirely  free  from  the  use  of  the  drug  at  the 
time  of  the  operation.  If  this  be  not  feasible,  sufficient  of  the 
drug  should  be  given  to  avoid  the  occurrence  of  confusing  symp- 
toms.    If  the  operation  be  imperatively  indicated  and  is  under- 


OBESITY  31 

taken  before  control  of  the  habit  is  possible,  the  drug  should  be 
given  on  the  day  of  the  operation  and  surely  immediately  after. 
The  writer  had  an  unfortunate  experience  of  this  sort.  The 
patient,  a  lady  of  55,  was  subjected  to  hysterectomy  for  uterine 
fibroid  complicated  by  tubal  abscess.  Not  until  she  developed  un- 
favorable symptoms  which  were  exceedingly  confusing  did  the 
patient's  son  make  the  attendants  aware  of  the  fact  that  the  patient 
had  used  large  quantities  of  morphin  daily.  The  drug  was  given 
at  once,  but  the  patient  died  before  the  symptoms  were  controlled. 

OBESITY 

Operative  technic  involving  remotely  situated  parts  and  or- 
gans is  made  exceedingly  difficult  by  the  presence  of  an  undue 
amount  of  adipose  tissue.  Obese  persons  do  not  repair  trauma 
with  the  same  promptness  as  obtains  in  those  endowed  with  a  nor- 
mal amount  of  adipose  tissue.  Adipose  tissue  of  necessity  has  less- 
ened resistance  to  infection.  In  instances  where  operation  is  to 
be  undertaken  at  a  more  or  less  remote  date  an  effort  should  be 
made  to  reduce  the  amount  of  fat  before  the  surgical  measure  of 
relief  is  undertaken.  In  operations  requiring  celiotomy  this  is 
an  exceedingly  important  consideration,  as  fat  persons  have  a 
large  amount  of  adipose  tissue  in  the  subperitoneal  tissue  and  in 
the  omentum. 

Most  writers  divide  adiposity  into  two  classes,  the  hereditary 
and  the  acquired  or  dietetic  kinds.  The  hereditary  form  of  obesity 
is  rare.  Its  occurrence  is  explained  on  the  theory  that  the  cell 
takes  on  a  maternal  or  paternal  impression  and  ultimately  develops 
that  impression.  Cases  of  so-called  hereditary  obesity  are  difficult 
to  manage  and  require  prolonged  and  persistent  treatment.  The 
regime  for  these  cases  is  similar  to  that  of  acquired  obesity.  To 
save  repetition  it  will  be  taken  up  under  that  head. 

Acquired  obesity  is  absolutely  and  alone  the  outcome  of  ex- 
cessive introduction  of  articles  of  diet  into  the  digestive  tract. 
Tissue  is  not  built  up  from  the  air.  With  this  principle  in  mind, 
firmly  fixed  and  unswayed  by  the  subterfuge  of  the  patient,  all 
cases  of  obesity  can  be  reduced  in  weight.  The  hardship  to  the 
appetite  and  love  of  indulgence  should  be  maintained  during  the 
period  devoted  to  the  preparation  of  the  patient  for  operation  and 


32  GENERAL  CONSIDERATIONS 

lie  be  given  the  mental  reservation  that  they  may  be  indulged 
again  when  the  operation  is  over.  This  is  not  unlike  promising 
a  child  candy  if  he  will  eat  meat  first,  but  the  method  has  its 
redeeming  features. 

Carbohydrates  contribute  most  largely  to  the  accumulation  of 
fats  in  the  body.  However,  large  quantities  of  proteids  will  also 
be  converted  into  fats.  This  latter  fact  must  be  borne  in  mind, 
and  the  patient  must  not  be  permitted  to  indulge  himself  up  to 
distention  with  proteids. 

The  presence  of  a  lung  or  heart  condition  causing  fatigue  read- 
ily, contributes  to  obesity  by  reducing  the  amount  of  work  the 
patient  feels  capable  of  doing.  Exercise  will  reduce  adipose  tissue, 
but  if  the  exercise  tend  to  overtax  the  heart  it  must  be  judiciously 
employed. 

On  the  whole,  a  diet  such  as  is  employed  in  diabetes  is  as  use- 
ful as  any.     (See  Diabetes,  page  34.) 

All  obese  persons  will  lose  weight  on  a  diet  consisting  entirely 
of  lean  meat  and  hot  water.  However,  this  is  a  rather  severe 
procedure  and  difficult  to  carry  out.  The  practitioner  need  not 
cling  absolutely  to  the  principle  of  the  withdrawal  of  the  carbo- 
hydrates, if  it  be  manifest  that  the  patient's  resistance  is  becoming 
low.  A  small  quantity  of  starchy  food  may  be  given,  but  it  should 
not  be  indulged  in  except  to  prevent  the  occurrence  mentioned. 
For  instance,  sugar  may  be  allowed  with  coffee  once  daily  and  a 
little  stale  bread  allowed  at  dinner.  Alcohol  in  all  forms  should 
be  avoided,  most  certainly  malt  liquors  should  be  absolutely  with- 
held. 

The  fats  and  oils  are  perhaps  less  objectionable  than  the 
starches,  but  as  little  of  these  as  exist  in  butcher's  meat  may  be 
allowed.  Butter  should  be  avoided.  This  applies  also  to  milk 
and  its  preparations. 

The  market  has  been  flooded  with  various  nostrums  exploited 
as  fat  reducers.  ]None  of  these  have  proven  of  value  unless  the 
diet  be  modified  at  the  same  time. 

Thyroid  extract  has  been  used  with  perhaps  more  success  than 
anything  of  similar  nature.  The  extract  is  given  in  tablets  of  five 
grains,  three  times  daily,  after  eating.  The  patient  should  be 
watched  for  circulatory  disturbances  during  its  administration — 
i.e.,  rapid  pulse,  slight  dyspnea,  dizziness  and  faintness.     When 


DIABETES  33 

these  symptoms  occur  administration  of  the  agent  should  be  dis- 
continued. 

In  healthy  persons  who  are  obese  as  the  outcome  of  indulgences 
alone,  the  measures  indicated  are  surely  effective.  Exercise  is  a 
most  valuable  aid  to  the  desired  end.  It  is  best  to  place  the 
patient  in  the  hands  of  a  skilled  trainer,  one  who  opposes  the 
patient's  efforts  and  grades  his  resistance  according  to  the  capa- 
bilities of  the  patient  rather  than  let  him  employ  apparatus.  If 
this  be  not  feasible,  the  patient  must  be  instructed  just  how  far 
he  is  to  go  with  his  work. 

It  is  a  somewhat  ridiculous  picture  to  see  a  man  with  a  wob- 
bling paunch  running  about  a  track  grunting  and  groaning,  with 
two  or  three  sweaters  wrapped  around  him,  taxing  a  sluggish  heart 
with  a  view  to  preparing  himself  for  a  surgical  operation.  On  the 
whole,  the  diet  is  the  sheet  anchor,  and  under  no  circumstances 
must  the  attendant  permit  of  any  modification  of  regime  beyond 
the  ones  mentioned. 

DIABETES 

Diabetics,  beyond  taking  very  badly  the  narcotics  by  inhala- 
tion, are  unfavorable  surgical  subjects,  as  they  do  not  readily  re- 
pair trauma.  In  diabetes  of  other  than  dietetic  origin  this  may 
be  due  to  general  arterial  disease. 

Purely  dietetic  diabetes,  or  at  least  glycosuria,  is  readily  rem- 
edied as  regards  the  preparation  of  patients  for  operation.  The 
other  forms,  while  not  so  certainly  benefited  by  treatment,  never- 
theless become  much  more  favorable  subjects  for  operation  if  the 
patient  be  subjected  to  dietetic  regime  for  a  period  of  several  weeks 
before  the  operation,  and  certainly  will  make  more  rapid  repair 
of  the  wound  if  the  regime  be  maintained  during  convalescence. 

In  these  cases  it  is  not  sufficient  to  inform  the  patient  what 
he  may  not  eat,  but  a  complete  diet  list  should  be  furnished,  stat- 
ing exactly  what  he  may  partake  of.  If  there  be  any  doubt  in 
the  patient's  mind  as  to  the  propriety  of  his  partaking  of  any 
special  dish,  he  need  only  be  informed  to  consult  his  diet  list,  and 
if  the  article  in  question  be  not  listed  it  is  not  proper  for  him  to 
consume  it. 

The  accompanying  diet  table  is  one  which  will  be  found  to 
meet  the  indications. 


34  GENERAL  CONSIDERATIONS 

DIET-TABLE 

In  the  strict  anti-diabetic  diet,  any  and  all  articles  not  men- 
tioned in  this  table  are  interdicted.  This  applies  especially  to 
milk,  which  should  never  be  used  in  any  form. 

BREAKFAST 

Beefsteak — Beefsteak  with  fried  Onions — Broiled  Chicken 
— Mutton  or  Lamb  Chops — Kidneys,  broiled,  stewed,  or  deviled 
— Tripe — Pig's  Feet — Game — Ham — Bacon — Deviled  Turkey  or 
Chicken — Sausage — Corned-beef  Hash,  without  Potato — Minced 
Beef,  Turkey,  Chicken,  or  Game,  with  poached  Eggs. 

All  kinds  of  Fish — Fish-roe — Fish-balls,  without  Potato. 

Eggs  cooked  in  any  way  except  with  Flour  or  Sugar — Scram- 
bled Eggs  with  chipped  Smoked  Beef — Picked  salt  Codfish  with 
Eggs — Omelets  plain  or  with  Ham,  with  Smoked  Beef,  Kidneys, 
fine  Herbs,  Parsley,  Truffles,  or  Mushrooms. 

Radishes — Cucumbers — Water-cresses — Butter — Pot-cheese. 

Tea  or  Coffee,  with  a  little  Cream  and  without  Sugar. 

Light  red  Wine  for  those  who  are  in  the  habit  of  taking  Wine 
at  Breakfast. 

LUNCH 

Chicken  Salad,  Lobster  Salad  (meat  of  the  Claws  only),  or 
any  kind  of  Salad  except  Potato— Fish  of  all  kinds,  Chops,  Steaks, 
Ham,  Tongue,  Eggs,  or  any  kind  of  Meat — Head-cheese. 

Red  Wine  or  dry  Sherry. 

DINNER 

Soups — Consomme  of  Beef,  of  Veal,  of  Chicken,  or  of  Turtle 
■ — Consomme  with  Okra — Ox-tail — Turtle — Terrapin,  without  the 
Liver — Chowder,  without  Milk  or  Potatoes — Mock  Turtle — Mul- 
lagatawny — Tomato — Gombo  filet. 

Fish,  etc.- — All  kinds  of  Fish — Lobsters  (meat  of  the  Claws 
only) — Terrapin,  without  the  Liver.  (No  Sauces  containing 
Flour  or  Milk.)' 

Relishes. — Pickles — Radishes — Celery — Sardines — Anchovies 
— Olives. 

Meats. — All  kinds  of  Meat,  cooked  in  any  way  except  with 


DIABETES  35 

Flour — all  kinds  of  Poultry,  without  dressings  containing  Bread 
or  Flour — Calf's  Head — Kidneys — Sweet-breads — Lamb-fries — 
Ham — Tongue — all  kinds  of  Game — Veal,  Fowl,  Sweet-breads, 
etc.,  with  Currie,  but  not  thickened  with  Flour.     (No  Liver.) 

Vegetables. — Truffles — Lettuce — Romaine — Chiccory — Endive 
— Cucumbers — Spinach — Sorrel — Beet  -  tops — Cauliflower — Cab- 
bage— Brussels  Sprouts — Dandelions  — Tomatoes  —  Radishes — 
Oyster-plant  —  Celery  —  Onions — Water-cresses — Artichauts — 
Jerusalem  Artichokes  —  Parsley  —  Mushrooms  —  All  kinds  of 
Herbs. 

Substitutes  for  Sweets — Saccharine  to  sweeten  coffee,  tea,  etc. 
Wine-jelly,  without  Sugar — Gelee  au  Kirsch,  without  Sugar — 
Gelee  au  Rhum,  without  Sugar — Gelee  au  Cafe,  without  Sugar — 
Omelette  au  Rhum,  without  Sugar — Omelette  a  la  Vanille,  with- 
out Sugar. 

MISCELLANEOUS 

Butter — Cheese  of  all  kinds — Eggs  cooked  in  all  ways  except 
with  Flour  or  Sugar — Sauces  without  Sugar,  Milk,  or  Flour. 

Almonds — Hazel-nuts — Walnuts. 

Tea  or  Coffee  with  a  little  Cream  and  without  Sugar. 

Alcoholic  Beverages. — Claret — Burgundy — Dry  Sherry — (No 
sweet  Wines.) 

PROHIBITED 

Bread,  Calce,  etc.,  made  with  Flour — Milk — Sugar — Desserts 
made  with  Flour  or  Sugar — Vegetables,  except  those  mentioned 
above — Sweet  Fruits. 

The  dietetic  regime  should  be  assiduously  carried  out  during 
the  repair  of  the  wound.  During  convalescence  the  ultimate  re- 
covery, that  is,  return  to  vigor,  may  be  delayed  as  the  outcome  of 
rigid  adherence  to  the  ritual.  In  these  instances  a  certain  modi- 
fication of  the  diet  is  permissible,  careful  watch  being  kept  of  the 
presence  of  sugar  in  the  urine,  which  may  reappear  or  increase  in 
quantity  as  the  result  of  the  ingestion  of  carbohydrates.  If  none 
appear  with  a  diet  to  which  moderate  amounts  of  carbohydrates 
are  added,  the  diet  may  be  constituted  in  this  way  for  a  consider- 
able period  of  time,  the  urine  being  kept  under  espionage  for  the 
purpose  of  developing  the  fact  whether  sugar  is  present  or  not. 


36  GENERAL   CONSIDERATIONS 

If  a  small  quantity  of  sugar  appear  in  the  urine  as  the  outcome 
of  dietetic  license,  this  may  be  regarded  as  a  minor  matter  com- 
pared to  the  benefit  derived  from  the  administration  of  moderate 
quantities  of  carbohydrates  during  recovery  from  a  surgical  opera- 
tion. If  the  sugar  is  not  made  to  disappear  entirely  from  the 
urine  as  the  result  of  the  diet,  and  the  administration  of  a  mode- 
rate amount  of  carbohydrates  in  the  diet  be  followed  by  a  sharp 
increase  of  glycosuria,  it  is  best  to  maintain  the  anti-diabetic 
regime  with  rigidity. 

As  already  stated,  the  wound  is  slow  to  heal  in  cases  of  gly- 
cosuria, and  the  immediate  repair  of  the  wound  should  provide 
for  drainage  for  this  reason,  with  the  view  of  removing  secretions, 
which,  if  retained,  are  likely  to  favor  infection. 

TRAINING   OF   TOLERANCE   FOR   MANIPULATION   OF 

CAVITIES 

In  a  general  way  it  may  be  said  that  patients  who  have  been 
subjected  to  manipulation  in  certain  portions  of  the  body  are  more 
tractable  to  the  measures  which  become  necessary  immediately 
after  operative  procedure.  For  instance,  a  case  of  carcinoma  of 
the  tongue  which  is  to  be  subjected  to  excision  will  have  to  be 
fed  by  means  of  a  sterile  stomach  tube  for  some  time  after  the 
operation. 

The  postoperative  vomiting  and  the  presence  of  infective  se- 
cretions in  the  mouth  require  thorough  cleansing  of  the  cavity  and 
the  introduction  of  food  by  tube. 

The  gagging  and  rebellion  at  the  measure  when  first  under- 
taken, immediately  or  soon  after  the  operation,  are  exhausting  and 
disturbing.  In  these  cases  it  would  be  well  to  create  a  tolerance 
for  that  sort  of  thing  by  educating  the  patient  in  this  regard.  The 
mouth  should  be  kept  clean  as  a  matter  of  course  because  of  the 
disease,  and  if  the  physician  sees  to  it  himself  that  the  patient  be- 
come habituated  to  the  procedure,  it  will  be  of  considerable  aid  to 
the  attendant  after  the  operation  has  been  performed,  in  carrying 
out  the  measures  required  at  that  time.  So  is  it  with  regard  to 
feeding  with  the  stomach  tube.  In  all  operations  about  the  mouth 
considerable  blood  secretions  and  solutions  are  swallowed  by  the 
patient  during  the  operation,  and  this  should  be  removed  by  wash- 


TRAINING  OF  TOLERANCE  FOR  MANIPULATION  OF  CAVITIES  37 

ing.  In  addition,  if  the  patient  be  trained  to  assist  in  the  intro- 
duction of  the  stomach  tube  before  the  operation,  the  necessary 
manipulation  will  be  found  much  easier  after  the  operation  is 
performed. 

The  same  principle  applies  to  the  rectum,  urethra,  and  vagina. 
Conditions  in  these  situations  which  necessitate  operation  usually 
call  for  more  or  less  prolonged  after-treatment,  and  if  the  patient 
be  accustomed  to  manipulation  the  expediency  of  the  after-treat- 
ment will  be  much  enhanced. 

These  form  a  factor  of  some  importance,  especially  when  the 
operation  is  undertaken  for  conditions  which  have  already  severely 
taxed  the  resistance  of  the  patient.  There  is  no  doubt  that  primary 
union  or  rapid  repair  will  take  place  most  readily  if  the  nutrition 
and  general  condition  of  the  patient  is  at  its  highest  possible  level 
during  the  period  immediately  following  a  severe  operation.  The 
pain,  annoyance,  and  apprehension  attendant  upon  the  first  post- 
operative manipulation  may  be  avoided  or  at  least  considerably 
lessened  if  the  factors  stated  above  be  regarded. 

This  is  best  exemplified  in  children  and  women  and  applies 
to  a  lesser  extent  to  men.  It  also  argues  for  the  viewpoint  from 
which  this  book  was  written,  that  a  large  proportion  of  the  neces- 
sary work  in  surgical  practice  is  advantageously  taken  up  by  the 
general  practitioner,  whose  relationship  to  the  patient  is  such  as 
to  warrant  the  expectation  that  the  best  possible  ultimate  results 
will  be  obtained  if  this  apparently  unimportant  element  of  the 
problem  be  handled  by  him. 


CHAPTEE    II 
PREPARATION    OF    THE    PATIENT 

The  sick  room — The  bed — Catharsis — General  preparation  of  the  patient — Diet 
— Preparation  of  the  operative  field  in  clean  cases — Preparation  of  the 
operative  field  in  infected  cases — Attire  of  patient  about  to  be  removed 
to  operating  room. 

THE   SICK  ROOM 

The  sick  room  should  be  large  and  sunny,  with  a  southern 
exposure.  It  should  be  entirely  emptied  before  being  occupied 
by  the  patient.  This  means  that  all  pictures  and  ornaments  are 
to  be  removed,  including  hangings  and  curtains.     The  walls  and 


ceiling  should  be  wiped  with  a  solution  of  corrosive  sublimate 
(1-1,000)  after  the  dust  from  mechanical  cleansing  has  settled. 
Dust  screens,  consisting  of  gauze  fastened  to  the  ordinary  adjust- 
able fly  screens,  should  be  placed  in  the  windows.  The  window 
38 


THE   BED 


39 


shades  should  be  removed,  unrolled,  wiped  with  corrosive  subli- 
mate solution,  and  replaced.  All  sewer  connections,  stationary 
wash  basins,  etc.,  should  be  sealed.  The  pictures,  etc.,  should  not 
be  replaced,  for  if  the  patient  becomes  delirious  they  might  pro- 
voke illusions. 

THE  BED 

The  bed  should  be  single,  with  freshly-aired  linen  and  a  rubber 
sheet  beneath  the  sheet.  A  plain  iron  bed  is  preferable  for  the 
purpose,  and  this  should  be  of  the  height  from  the  floor,  usually 
used  in  hospitals  (26  inches  to  the  top  of  the  fabric).     (Fig.  10.) 


Fig.  11. — Bed  Suitable  for  Head  Cases. 


The  illustration  shows  a  bed  with  a  rather  high  head-piece.  This 
is  desirable  in  certain  cases,  especially  when  it  is  expedient  after 
the  operation  to  raise  the  upper  portion  of  the  patient's  body  on 
pillows,  such  as  is  the  case  following  gastro-enterostomy.  On  the 
other  hand,  the  bed  shown  in  Fig.  11  is  more  serviceable  in  cases 
involving  operations  on  the  scalp  and  skull,  the  low  head-piece 
making  these  parts  more  readily  accessible,  in  changing  dressings, 
etc.  An  ordinary  iron  bed  may  be  raised  on  improvised  wooden 
stilts  having  a  socket  for  the  reception  of  the  bedposts  (Fig.  12). 

This  arrangement  renders  the  patient  more  accessible  to  the 
attendant  and  nurse.  A  desirable  refinement  which  contributes 
not  a  little  to  the  facility  with  which  the  necessary  manipulations 
are  performed.     Also,  the  space  under  the  bed  is  more  readily 


40 


PREPARATION   OF   THE   PATIENT 


kept  clean,  and  the  fact  that  this  is  visible  prevents  the  placing 
of  bed  pans  or  other  objectionable  apparatus  under  the  bed. 

If  feasible,  the  bed  should  be  so  placed  as  to  render  both  sides 
of  the  patient  readily  accessible  at  the  same  time.  This  enables 
the  attendant  to  approach  the  patient  from  one  side  of  the  bed, 
and  the  nurse  to  supply  needed  dressings,  etc.,  from  the  other. 

A  serviceable  arrangement  of  the  sick  room  is  shown  in  Fig.  12. 


Fig.  12. — Arrangement  of  Bed  and  Sick  Room  in  Private  Practice. 


The  light  comes  into  the  chamber  from  two  directions.  The 
patient  utilizes  that  coining  from  behind  the  bed  for  reading, 
and  the  light  entering  at  the  side  is  available  for  the  purpose  of 
dressing  the  wound,  scrutinizing  the  patient,  etc. 

When  convalescence  is  established,  various  ornaments  may  be 
placed  in  the  room,  and  these  replaced  by  others  at  intervals  with 
the  view  of  interesting  the  patient. 

Besides  the  bed,  the  room  should  contain  a  small  oblong  table 
covered  with  a  clean  towel  or  folded  sheet  upon  which  dressings, 
medicines,  etc.,  for  use  of  the  nurse  may  be  placed.  Bed  pans, 
catheters,  etc.,  should  be  placed  in  a  convenient  closet  not  within 
sight  of  the  patient. 

The  temperature  of  the  room  should  be  maintained  at  about 


CATHARSIS  41 

70°  F.,  and  it  should  be  ventilated  thoroughly  at  least  once  a  day, 
taking  care  that  the  patient  be  protected  from  sudden  changes  of 
temperature. 

The  room  must  be  kept  scrupulously  clean  during  the  after- 
treatment.  Dusting  should  be  done  with  a  damp  cloth.  The  nurse 
in  charge  of  the  case  should  take  care  of  the  cleansing  of  the  room 
herself,  and  this  labor  should  not  be  turned  over  to  domestics  or 
members  of  the  patient's  family. 

The  patient  should  be  kept  in  bed  for  the  entire  day  before 
the  operation  and  half  the  preceding  day. 

CATHARSIS 

Thirty-six  hours  before  the  operation  five  grains  of  calomel 
are  administered.  This  is  followed  the  next  morning  by  half  an 
ounce  of  Sal  Roehelle.  At  noon  an  enema  of  soap  and  water  is 
given  and  if  regarded  necessary,  because  of  moderate  action  from 
the  measures  already  employed,  the  enema  is  repeated  in  the  even- 
ing. Subsequent  to  this  no  further  disturbance  of  the  contents 
of  the  bowel  is  permitted,  on  the  ground  that  a  stool  just  before 
an  operation  is  objectionable  for  obvious  reasons,  among  which 
may  be  mentioned  the  fact  that  during  the  straining  incident  to 
the  primary  stage  of  narcosis  a  stool  may  be  discharged,  render- 
ing the  precautions  already  mentioned  negative. 

Because  of  this  possibility  some  surgeons  do  not  administer  a 
cathartic  for  twice  twenty-four  hours  before  the  operation.  When 
it  is  remembered  that  the  gut  is  an  exceedingly  important  elimina- 
tive  organ,  and  that  decomposition  of  the  end  products  of  diges- 
tion will  take  place  at  times  in  a  few  hours,  and  that  the  technic 
of  abdominal  operations  is  not  a  little  more  difficult  when  distended 
gut  is  persistently  obtruded  into  the  wound,  the  latter  rule  is  per- 
haps not  as  universally  to  be  recommended  as  the  former.  Indeed, 
the  practitioner  should  in  this  regard,  as  in  all  other  problems, 
not  cling  to  a  hard  and  fast  rule,  but  make  use  of  the  general  prin- 
ciple laid  down  and  modify  it  to  meet  the  immediate  indications. 

If  the  operation  is  to  be  performed  in  the  morning  the  thirty- 
six  hour  rule  is  a  good  one,  but  it  is  to  be  remembered  that  the 
morning  hour  for  operation  is  not  always  without  objections,  not 
the  least  of  which  is  the  fact  that  the  immediate  preparation  of 


42  PREPARATION   OF  THE   PATIENT 

all  the  paraphernalia  necessary  to  a  major  operation  consumes 
much  time,  and  that,  as  a  rule,  the  assistants  who  do  this  work  are, 
for  many  causes  incident  to  the  common  mode  of  life,  apt  to  be 
late  at  their  posts  and  to  hurriedly  and  perhaps  more  or  less  in- 
differently perform  their  duties.  It  is  not  by  any  means  uncom- 
mon to  find  that  the  best  interests  of  the  patient  are  conserved  by 
a  more  leisurely  preparation  for  the  operating  room  during  hours 
most  usually  devoted  to  work  by  the  vast  majority  of  people. 

If,  then,  the  operation  is  to  be  performed  in  the  afternoon,  the 
last  enema  should  be  given  at  7  a.m.  ;  that  is,  beginning  the  morn- 
ing of  the  day  preceding  the  operation  the  calomel  is  given  at  10 
a.m.,  the  saline  at  3  p.m.,  the  first  enema  at  8  p.m.,  and  the  last 
cleansing  enema  at  seven  of  the  morning  of  the  day  of  the  opera- 
tion, and  the  operation  done  at  2  o'clock  or  later  in  the  day. 

With  this  arrangement,  the  patient  goes  to  bed  at  the  usual 
hour  the  night  preceding  the  day  before  the  operation  and  remains 
in  bed  the  next  day  and,  indeed,  until  the  time  of  operation.  The 
bath  is,  of  course,  given  on  the  evening  preceding  the  day  before 
the  operation. 

GENERAL   PREPARATION   OF   PATIENT 

Kocher  insists  that  the  patient  be  given  a  complete  bath  the 
day  before  the  operation.  The  bath  is  taken  in  a  warm  bath  room, 
and  the  patient  liberally  lathered  with  soap  by  an  assistant. 
Kocher  regards  mechanical  cleansing  as  more  effective  than  the 
effort  to  neutralize  infective  material  with  antiseptics.  The  sur- 
gical cleansing  includes  the  scalp,  hair,  finger  nails,  mouth, 
pharynx,  and  genitals. 

He  regards  antiseptic  applications  as  irritating  and  liable  to 
provoke  eczema,  and  believes  it  is  sufficient  to  wash  the  operation 
field  with  ether  and  alcohol  after  it  has  been  shaved  and  thor- 
oughly cleansed  with  soap  and  water;  this  is  to  be  followed  by 
an  aseptic  protective  dressing.  In  the  presence  of  skin  disease, 
however,  antiseptics  are  to  be  employed. 

Kocher  also  advises  cleansing  of  mucous  membranes  which 
are  in  communication  with  the  air.  The  mouth  and  nose  should 
be  cleansed.  Tartar  is  removed  from  the  teeth,  preferably  by  the 
dentist,  this  to  be  followed  by  thorough  cleansing  with  soap  and 


GENERAL   PREPARATION   OF   PATIENT  43 

water  and  lavage  with  a  one-fourth  per  cent,  carbolic  acid  solution. 
Strong  antiseptics  in  the  mouth  and  nose  give  rise  to  hyperse- 
cretion and  do  more  harm  than  good.  Nasal  crusts  are  readily 
removed  with  a  solution  of  sodium  bicarbonate  (page  362).  Plugs 
of  sebum  are  to  be  removed  from  the  tonsil. 

Moynihan  has  each  patient  furnished  with  a  new  tooth-brush 
and  a  bottle  of  antiseptic  mouth  wash,  and  the  nurse  is  instructed 
to  cleanse  the  mouth  every  two  or  three  hours  during  the  day. 
Harvey  Cushing  has  shown  that  by  careful  attention  to  cleansing 
of  the  mouth,  and  by  the  sterilization  of  the  food,  the  alimentary 
canal  may  be  rendered  comparatively  sterile.  The  import  of  the 
latter  proposition  will  be  more  extensively  considered  in  connec- 
tion with  the  preparation  of  patients  for  operations  on  the  gastro- 
intestinal canal  (page  424).  Parotiditis  and  aspiration  pneu- 
monia are  both  liable  to  occur  from  neglect  of  thorough  cleansing 
of  the  teeth  and  mouth. 

The  fact  that  absolute  inactivity  on  the  part  of  the  patient 
immediately  after  an  operation  is  necessary  for  many  reasons, 
makes  it  difficult  for  the  nurse  to  give  attention  to  the  care  of  the 
hair.  In  female  patients  this  is  an  important  factor.  The  head 
is  to  be  shampooed  the  day  before  the  operation,  which  may  be 
done  at  the  time  the  bath  is  given.  After  thorough  drying,  an 
ointment  containing  a  small  portion  of  sulphur  should  be  rubbed 
into  the  scalp.  This  will  prevent  the  caking  of  excessive  secretion 
of  sebum,  especially  should  the  patient  be  bedridden  for  a  consid- 
erable period  of  time  after  the  operation.  The  hair  is  then  braided 
and  fastened  to  the  top  of  the  head.  If  delirium  occur,  the  pres- 
ence of  the  hair  on  the  back  of  the  head  is  objectionable  and  a 
source  of  annoyance  as  the  patient  tosses  from  side  to  side. 

In  male  patients  it  is  best  to  cut  the  hair  quite  short  and  rub 
in  the  sulphur  ointment.  The  beard  should  be  trimmed  close  if 
shaving  is  not  permitted.  The  almost  inevitable  vomiting  fol- 
lowing operations  soils  the  beard,  and  should  cleansing  be  post- 
poned as  the  outcome  of  the  necessity  of  maintaining  absolute 
quiet  for  a  considerable  time,  is  a  source  of  infection  which  should 
be  avoided. 

The  scalp  encrusted  with  sebaceous  secretion  is  an  exceedingly 
favorable  "  nahrboden  "  for  bacteria,  and  it  is  not  uncommon  to 
see  a  patient  scratch  the  scalp  and  hold  the  finger  nails  charged 


44  PREPARATION   OF  THE  PATIENT 

with  bacteria  over  the  wound  as  the  surgeon  changes  the  dress- 
ing. Patients  will  reach  for  the  region  of  the  surgical  trauma 
when  painful  manipulations  take  place,  and  though  ordered  to 
"  keep  the  hands  away,"  usually  disregard  the  admonition  until 
after  the  damage  is  done. 

Incidentally  it  would  be  well  for  the  surgeon  to  bear  in  mind 
the  necessity  for  a  clean  scalp,  as  it  not  infrequently  happens  that 
sebum  falls  from  the  head  to  the  wound  as  the  surgeon  is  bending 
over  the  patient  changing  a  dressing.  Indeed,  hospital  internes 
serving  with  the  writer  are  not  permitted  to  wear  a  beard,  and  are 
compelled  to  keep  the  hair  of  the  scalp  short.  As  a  rule,  this  is 
not  a  hardship  to  members  of  the  house  staff,  as  they  are  usually 
at  a  time  of  life  when  a  beard  is  not  worn.  However,  it  is  respect- 
fully suggested  that  surgeons  do  away  with  beards  or  at  least  wear 
them  closely  trimmed. 

DIET 

It  would  seem  most  rational  to  administer  to  patients  about 
to  be  operated  on  a  diet  which  will  leave  the  least  residue,  require 
the  least  possible  effort  in  the  process  of  digestion,  and  at  the  same 
time  not  reduce  the  resistance  of  the  patient.  If  the  patient  pre- 
sents no  complication,  such  as  is  taken  up  in  the  preceding  chap- 
ter, the  matter  is  a  simple  one.  These  considerations  have  been 
sufficiently  discussed  and  do  not  call  for  reiteration  here. 

Unless  specially  contraindicated  the  meal  taken  thirty-six 
hours  before  the  operation  may  consist  of  all  the  three  general 
divisions  of  substances  of  diet,  i.e.,  proteid,  carbohydrate,  and 
fat.  It  is  difficult  to  see  why  any  hardship  should  evolve  on  the 
patient  in  this  respect,  as  this  meal  will  undoubtedly  be  entirely 
consumed  by  the  next  morning.  If  restriction  be  made  at  all  the 
patient  is  ordered  to  use  only  lean  meat,  and  well  hydrated  carbo- 
hydrates, i.e.,  a  light  dinner  may  be  taken  consisting  of  chicken, 
a  fresh  vegetable,  and  toasted  bread. 

During  the  day  before  the  operation,  i.e.,  when  the  patient  is 
in  bed,  the  diet  should  be  more  restricted.  Much  has  been  said 
of  the  value  of  fluid  forms  of  proteids  of  various  kinds,  yet  it  is 
no  doubt  the  opinion  of  most  clinicians  that  none  of  these  contain 
the  essential  albuminoid  or  proteid  necessary  to  the  proper  nour- 
ishment of  the  human  animal.     None  of  the  preparations  on  the 


DIET  45 

market  to-day  are  regarded  by  the  writer  as  of  genuine  nutritive 
value.  They  have  a  certain  place,  they  please  the  sense  of  taste 
perhaps,  or  render  other  substances  less  monotonous,  yet  they  con- 
sist very  largely  of  the  inorganic  salts  and  certain  flavors  extracted 
from  meat  fiber,  and  do  not  contain  the  necessary  and  eminently 
essential  proteid. 

However,  milk  contains  all  the  elements  necessary  to  the  main- 
tenance of  human  life,  and,  indeed,  in  a  readily  assimilable  form. 
It  has  been  proven  again  and  again  that  adult  life  can  be  main- 
tained indefinitely  on  a  purely  milk  diet.  Not  alone  is  this  true, 
but  the  physical  endurance  of  individuals  who  are  subsisting  en- 
tirely on  milk  is  as  great  as  that  of  persons  taking  ordinary  ar- 
ticles of  diet. 

Milk  is  deficient  in  iron.  However,  for  the  purpose  of  prepar- 
ing a  patient  for  operation,  this  fact  may  be  disregarded.  It  is 
perhajDS  true  that  the  casein  of  milk  causes  fermentation  in  certain 
individuals.  This  may  be  overcome  by  the  addition  to  the  milk 
of  lime  water,  or  by  peptonizing  it.  As  a  general  rule,  milk  ob- 
tained from  a  properly  regulated  dairy,  properly  handled,  in  a 
manner  now  so  widely  understood,  is  as  universally  useful  an  ar- 
ticle of  diet  as  can  be  employed  during  the  day  immediately  pre- 
ceding an  operation.  The  quantity  should,  according  to  the 
weight  of  the  patient,  be  between  two  and  four  quarts  in  the  day, 
but  rarely  less  than  the  two  quarts.  Eggs,  given  raw  or  made  into 
a  custard,  may  be  allowed,  and  if  the  milk  be  given  besides,  the 
quantity  may  be  correspondingly  reduced. 

The  writer  warns  against  the  indulgence  in  fads  in  this  re- 
gard. The  starvation  of  patients  for  a  day  or  two  before  an  oper- 
ation is  absolutely  unscientific  and  irrational.  It  is  perfectly 
easy  to  see  that  a  patient  about  to  be  subjected  to  a  severe  strain 
upon  the  vital  forces  is  better  able  to  withstand  the  trial  if  the 
energies  have  been  conserved  by  the  proper  administration  of  food, 
which  is,  of  course,  the  only  source  of  energy  there  is.  Whatever 
objections  there  may  be  to  a  diet  of  milk  and  eggs  as  regards  its 
disturbing  influence  on  digestion  in  certain  cases  need  not  be 
considered  in  this  connection.  The  patient  will  be  in  bed,  under- 
going preparation  for  an  operation,  and  if  he  have  some  digestive 
disturbance  this  may  be  readily  neutralized  by  catharsis,  etc., 
which  is,  as  already  stated,  a  part  of  the  preparation  for  opera- 


46  PREPARATION   OF   THE   PATIENT 

tion,  and  if,  last  of  all,  the  digestion  of  milk  and  eggs  be  accom- 
panied by  distress,  it  is  well  for  the  patient  to  accept  the  situa- 
tion for  the  period  of  time  indicated,  in  order  to  achieve  the  bene- 
fits of  increased  resistance,  the  outcome  of  the  diet. 

Of  course  no  food  whatever  is  given  for  six  hours  before  the 
operation.  The  last  nutritive  substance  introduced  into  the 
stomach  may  consist  of  properly  prepared  milk. 

PREPARATION   OF   THE   OPERATIVE   FIELD   IN    CLEAN 

CASES 

It  is  quite  impossible  to  sterilize  absolutely  the  skin.  This  is 
due  to  the  fact  that  the  hair  follicles  and  ducts  of  the  sebaceous 
and  sudoriperous  glands  are  the  habitat  of  bacteria  and  that  these 
cannot  be  removed  or  entirely  destroyed.  It  is  probable  that  great 
activity  of  the  skin,  i.e.,  sweating,  will  mechanically  remove  bac- 
teria from  the  location  mentioned.  This  explains  the  rationale 
of  a  warm  bath  before  an  operation.  The  perspiration  is  fertilized 
as  it  passes  along  the  ducts  through  the  skin.  If  perspiration  be 
prolonged  the  sweat  becomes  quite  sterile.  However,  the  quantity 
of  excretion  must  be  large  before  this  is  accomplished. 

In  this  connection  it  is  proper  to  say  that  rarely,  if,  indeed, 
ever,  is  the  technic  of  an  operation  achieved  without  contami- 
nation of  some  kind.  Infection  is  the  outcome  of  fertilization. 
Infection,  at  the  same  time,  requires  a  certain  dosage  of  fertiliza- 
tion. The  aim  of  the  surgeon  should,  therefore,  be  to  lessen,  as 
much  as  is  possible,  the  dose  of  infective  substance  and  thus  ac- 
complish an  aseptic  result.  This  justifies  the  elaborate  prepara- 
tion employed  in  properly  conducted  operating  rooms. 

Again,  it  is  worthy  of  note  that  infection  occurs  more  readily 
in  even  the  best  equipped  operating  rooms  than  it  does  in  private 
residences  where  no  case  has  ever  before  been  subjected  to  opera- 
tion.    This  should  be  explained  by  the  facts  stated  above. 

Infection,  too,  is  rare  where  large  quantities  of  fluids  are  used 
in  cleansing,  provided  the  fluid  is  free  from  bacteria,  i.e.,  the  bac- 
teria present  in  a  given  area  will  exhaust  themselves  in  a  sterile 
media  and  die,  if  they  have  to  fertilize  an  overwhelmingly  large 
sterile  area.  This  is  along  the  lines  of  the  law  of  dilution  and 
sedimentation.     A  typhoid  stool  deposited  fifty  or  sixty  miles 


PREPARATION   OF   OPERATIVE  FIELD   IN   CLEAN   CASES       47 

away  from  the  place  where  water  is  used  for  drinking  purposes 
will  be  so  diluted  after  the  water  has  traveled  the  distance  as  to 
do  no  harm,  especially  if  the  watershed  be  added  to  by  tributaries 
free  from  typhoid  bacteria  en  route. 

This  principle  should  be  borne  in  mind.  Cleansing  of  the  skin 
has  its  physics  as  well  as  a  chemistry  and  a  physiology.  As  a  gen- 
eral rule,  antiseptics  must  remain  in  contact  with  bacteria  for  a 
long  time  in  order  to  destroy  them.  It  would  be  better  to  lavage 
a  given  area  of  skin  with  several  gallons  of  boiled  water  than  to 
sop  on  the  area  a  small  quantity  of  an  aseptic  solution,  i.e.,  if  the 
contention  expressed  above  is  logical. 

Bacteria  are  certainly  more  readily  attacked  in  fluid  sebum 
than  when  they  inhabit  dry  collections  of  sebaceous  matter  which 
plug  up  the  excretory  passages  of  the  skin.  We  have,  then,  the 
epidermis,  the  excretory  ducts,  and  the  hair  to  consider  as  the 
parts  in  which  bacteria  habitually  reside. 

The  hair  is  removed  by  shaving.  The  excretory  ducts  are 
opened  by  warmth  and  consequent  perspiration,  the  epidermis  is 
softened  with  water  and  the  residual  sebum  is  saponified  with 
soap  which  is  sufficiently  alkaline  to  form  a  saponification  with 
the  fat  in  the  sebum,  and  is  mechanically  removed  by  liberal  lav- 
age with  sterile  water. 

The  problem  is  thus  discussed  rather  at  length,  on  the  ground 
that  the  laying  down  of  hard  and  fast  rules  is  not  wise,  for  the 
surgeon  has  not  always  available  everything  which  would  make 
possible  the  carrying  out  of  certain  measures,  and  if  the  principle 
here  laid  down  is  borne  in  mind,  the  desired  result  may  be  achieved 
in  many  ways.  Certain  methods  of  skin  cleansing  will  be  here 
stated,  but  they  may  be  modified  at  will,  provided  the  general  prin- 
ciple is  adhered  to. 

Dry  serum  may  be  rendered  fluid  by  oil.  Therefore,  the  skin 
to  be  sectioned  may  be  gently  anointed  with  olive  oil  which  has 
been  boiled.  This  is  left  in  contact  with  the  skin  for  several 
hours,  and  is  applied  immediately  after  the  general  bath.  The 
area  is  then  thoroughly  soaped  and  the  hair  shaven. 

Shaving  is  an  art.  Aside  from  the  pain  and  annoyance  to  the 
patient  consequent  to  the  use  of  a  dull  razor,  especially  in  un- 
trained hands,  the  skin  is  likely  to  be  scratched  and  the  little  raw 
surfaces  left  are  favorable  places  for  the  invasion  of  infection. 


48  PREPARATION   OF   THE   PATIENT 

JSTurses  should  be  trained  to  shave  properly.  In  male  cases  it  is 
best  to  have  the  part  shaven  by  a  barber  if  this  be  feasible.  Fe- 
male patients,  as  a  rule,  and  occasionally  male  patients,  object  to 
being  shaved  on  portions  of  the  body  usually  covered  by  the  cloth- 
ing. Frequently  female  nurses  are  diffident  about  attacking  the 
area  with  a  razor.  In  these  instances,  if  there  be  ample  time  for 
preparation,  it  is  perhaps  justifiable  to  use  a  depilatory  mixture. 
The  following  formula  has  been  compiled  by  Dr.  W.  E.  Dreyfuss, 
and  is  efficacious : 

Barii  sulphid parts  25 

Saponis  pulvis parts     5 

Talci  veneti  pulv parts  35 

Tritici  farine parts  35 

Benzaldehydi    q.   s. 

Make  teaspoonful  of  the  powder  into  a  paste  with  three  teaspoon- 
fuls  of  water,  and  apply  to  the  parts  with  an  ordinary  shaving 
brush  in  a  moderately  thick  and  even  layer.  After  four  to  five 
minutes  the  parts  should  be  moistened  with  a  sponge  and  after 
another  five  minutes  the  hair  can  be  removed  by  washing  off  the 
mass.  The  part  is  then  deluged  with  a  large  quantity  of  sterile 
water  of  a  temperature  of  100°  F. 

For  this  purpose  the  patient  is  placed  on  a  large-sized  "  Kelly 
pad"  (Fig.  13).  The  illustration  shows  three  forms  of  Kelly 
pads  suitable  for  various  purposes.  A  is  a  form  very  serviceable 
in  dressing  abdominal  wounds,  the  apron  being  carried  over  the 
edge  of  the  bed  or  table,  and  the  cleansing  fluid  allowed  to  run 
down  on  either  side  of  the  patient's  body,  being  led  into  a  proper 
receptacle  by  means  of  the  apron.  B  and  C  are  similar  in  essential 
respects,  except  that  the  apron  of  B  may  be  hooked  upon  itself 
and  form  a  receptacle  for  the  cleansing  fluids.  Both  B  and  C  are 
largely  employed  in  cases  of  operations  and  cleansing  of  wounds 
with  the  patient  in  the  lithotomy  position.  The  pad  rests  under 
the  patient's  buttocks,  and  the  apron  hangs  over  the  end  of  the 
table.  The  pad  is  made  of  rubber  and  the  edge  is  furnished  with 
an  air  compartment  which  is  blown  up  through  the  little  metal 
tube  visible  at  the  edge.  The  metal  tube  is  supplied  with  a  valve 
which  permits  air  to  enter,  but  none  to  come  out.  This  arrange- 
ment prevents  the  cleansing  fluids  from  wetting  the  bed.    Next,  a 


PREPARATION   OF   OPERATIVE   FIELD   IN   CLEAN  CASES     49 


sterile  pad  is  applied  to  the  part,  wet  with  sterile  water,  and  left 
in  contact  with  the  skin  for  several  minutes.     The  water  again 


a  b  c 

Fig.  13. — Kelly  Pads.     A,  used  for  cleansing  abdomen;    B  and  C,  used  for  cleans- 
ing perineum  with  patient  in  lithotomy  position. 

should  be  warm,  not  hot,  as  hot  water  irritates,  but  warm  enough 
to  aid  in  emptying  the  sweat  ducts.  It  also  softens  the  epidermis, 
which  is  then  more  readily  removed.    After  removing  the  wet  pad 


Fig.  14. — Rubber  Sponge  for  Cleansing  Skin. 

the  skin  is  thoroughly  soaped  with  tincture  of  green  soap,  using  a 
piece  of  gauze  or  a  rubber  sponge  (Fig.  14),  not  a  brush.     These 


50  PREPARATION   OF  THE   PATIENT 

sponges  may  be  boiled,  and  they  make  a  lather  more  readily  than 
gauze.  The  writer  has  seen  the  skin  made  to  bleed  by  an  over- 
strenuous  assistant,  and  has  been  compelled  to  postpone  the  open- 
ing of  a  knee  joint  for  this  reason.  The  soaping  should  be  gentle 
and  somewhat  prolonged,  causing  a  free  lather,  which  is  ultimately 
displaced  by  a  liberal  lavage  with  sterile  water. 

Ether  is  next  poured  over  the  skin.  The  ether  is  used  with  the 
view  of  removing  the  small  portion  of  oil  which  still  occupies  the 
excretory  ducts.  This  is  a  useful  measure  when  properly  used,  but 
it  is  to  be  remembered  that  ether  evaporates  very  rapidly,  and  if  it 
have  in  solution  any  oil,  will  leave  the  latter  in  contact  with  the 
skin  in  the  form  of  an  exceedingly  thin  film,  which  is,  of  course, 
not  fluid  because  of  the  refrigeration  from  the  ether ;  thus  the  appli- 
cation of  ether  may  do  more  harm  than  good. 

The  application  of  ether  to  be  eifective  must  be  immediately 
dislodged  by  a  large  quantity  of  sterile  water  at  a  temperature  of 
about  80°  F.,  for  ether  boils  at  the  temperature  of  the  body  and 
may,  when  mixed  with  hot  water,  burn  the  dependent  parts  of  the 
body,  especially  if  proper  drainage  be  not  provided  for. 

The  part  is  now  covered  with  a  protective  dressing,  consisting 
of  a  thick  layer  of  sterile  gauze,  on  top  of  which  a  layer  of  cotton 
is  placed,  the  latter  being  impervious  to  bacteria.  The  dressing  is 
held  in  place  with  appropriate  binders  or  bandages. 

The  measures  related  above  have  proven  effective  in  the  hands 
of  the  writer.  However,  if  they  be  not  feasible  because  of  the 
cumbersomeness  of  the  manipulations,  antiseptics  may  be  used. 

Moynihan  has  the  skin  cleansed  with  soap  and  water  much  in 
the  same  way  as  is  mentioned,  using  a  wipe  for  the  purpose.  An 
antiseptic  compress  is  then  applied  and  left  for  twenty-four  hours. 
The  compress  consists  of  two  or  three  layers  of  lint  soaked  in  1 
per  cent,  formalin,  1  in  60  carbolic',  or  1  in  2,000  biniodid  of 
mercury  solution.  He  prefers  the  former,  believing  a  deeper  pene- 
tration of  the  skin  and  glands  is  obtained.  In  any  event,  the  lat- 
ter two  solutions  are  quite  apt  to  irritate.  There  can  be  no  objec- 
tion to  this  method  if  it  be  supplemented  with  large  quantities  of 
sterile  lavage.  At  the  end  of  twenty-four  hours  a  second  washing 
is  performed  and  a  second  compress  applied.  Moynilian  does  not 
insist  upon  the  second  washing,  as  it  is  a  trifle  trying  to  a  delicate 
skin. 


PREPARATION  OF  OPERATIVE  FIELD  IN  INFECTED  CASES      51 

Whatever  method  is  used,  the  case  should  be  cleansed  again 
upon  the  operating  table.  It  would  seem  that  as  a  general  rule 
the  second  washing  may  be  omitted.  If  there  should  be  any  small 
furuncles  or  cracks  in  the  skin,  they  should  be  rendered  sterile 
with  pure  carbolic  acid.  The  acid  is  applied  with  a  cotton  daub 
twisted  on  the  end  of  a  probe  and  the  acid  neutralized  with  alcohol 
at  the  end  of  a  few  moments.  The  actual  cautery  may  be  em- 
ployed for  the  purpose. 

PREPARATION   OF   THE    OPERATIVE    FIELD  IN   INFECTED 

CASES 

Operation  on  patients  who  present  infection  require  slightly 
different  preparation. 

The  general  principle  is  that  of  antisepsis  rather  than  asepsis. 
If  infection  exists,  it  means  that  the  character  of  the  fertilization 
is  such  as  to  have  overcome  resistance,  and  it  is  probable  that  the 
method  of  sterilization  of  the  field  of  operation  effective  in  clean 
cases  requires  additional  chemical  aid. 

That  it  is  feasible  to  obtain  aseptic  repair  of  the  skin  in  the 
presence  of  infection  is  proven  by  the  fact  that  operations  per- 
formed within  an  area  of  erysipelas  have  given  this  result.  These 
operations  in  the  hands  of  the  writer  have  been  undertaken  under 
antisepsis.  It  is  not  improbable  that  the  incision  within  the  zone 
of  erysipelatous  inflammation  and  the  liberal  lavage  with  corro- 
sive sublimate  solution  has  a  beneficial  effect  upon  the  erysipelas 
itself,  a  conclusion  which  is  justified  on  the  ground  that  the  in- 
fected tissue  was  made  more  accessible  to  the  direct  contact  with 
the  antiseptic. 

Indeed,  the  writer  has  attacked  the  mastoid  cells,  the  lateral 
sinus  and  the  internal  jugular  vein  through  an  erysipelatous  zone 
with  favorable  outcome.  Maylard  has  removed  sequestra  from 
long  bones  in  cases  where  sinuses  existed,  both  in  tuberculous  osteo- 
myelitis with  mixed  suppurative  infection,  and  in  suppurative 
osteomyelitis  of  long  standing  with  aseptic  healing.  In  these  cases 
microscopical  examinations  of  scrapings  of  the  epidermis  contigu- 
ous to  the  sinuses  and  of  small  portions  of  skin  excised  from  the 
region  of  the  sinuses  have  shown  no  bacteria. 

The  preparation  of  these  cases  is  as  follows :  The  skin  is  an- 
6 


52  PREPARATION   OF   THE   PATIENT 

ointed  freely,  but  not  forcibly,  with  20  per  cent,  oleate  of  mercury. 
The  applications  extend  over  several  days  and  are  employed  over 
the  entire  field  of  operation  twice  daily.  Before  each  application 
following  the  first  one  the  residual  oleate  and  the  softened  epi- 
dermis is  removed  by  careful,  prolonged,  but  gentle  soaping  with 
a  gauze  wipe  and  the  combination  of  soap,  oil,  sebum,  and  bac- 
teria mechanically  removed  with  a  solution  of  corrosive  sublimate 
1  in  1000.  The  solution  is  poured  onto  the  field  from  a  pitcher 
and  a  gallon  used  at  each  sitting. 

This  procedure  is  carried  out  morning  and  evening  for  three 
days  before  the  operation.  At  the  last  cleansing — i.e.,  the  one  on 
the  evening  before  the  day  of  the  operation — the  sinuses,  if  any, 
are  wiped  out  with  pure  carbolic  acid  and  this  neutralized  with 
alcohol.  Then  a  dressing  is  applied  similar  to  that  mentioned 
above.     (Page  50.) 

]STo  application  of  the  oleate  is  made  at  this  time.  Here  again 
modification  of  detail  is  permissible,  i.e.,  carbolic  acid  solution  1 
per  cent,  or  formalin  solution  1  per  cent,  may  replace  the  corrosive 
sublimate  solution.  Carbolic  acid  solution  will  soften  the  epi- 
dermis more,  but  will  also  cause  maceration  of  the  true  skin  if 
applied  for  too  long  a  time.  This  objection  does  not  apply  to 
formalin,  but  the  latter  is  more  irritating  than  corrosive  sublimate. 

The  theory  is  palpable.  The  skin  is  penetrated  by  the  oleate 
of  mercury,  the  bacteria  destroyed  and  later  removed  by  lavage. 
It  is  probable  that  repeated  application  of  the  procedure  is  neces- 
sary to  accomplish  the  desired  end.  As  in  clean  cases,  the  bath  and 
warm  water  are  used.  Indeed,  the  method  is  quite  similar  to  that 
used  in  clean  cases  except  for  the  employment  of  antiseptics  and 
the  somewhat  more  protracted  preparation. 

To  prevent  contamination  of  the  operation  field  from  the  con- 
tiguous skin  Murphy  of  Chicago  employs  the  following  measure. 

After  preparation  of  the  skin  in  the  usual  way  a  "  rubber 
dam  "  is  applied  to  the  field  of  operation,  consisting  of  a  thin  sheet 
of  elastic  rubber  of  about  the  thickness  of  the  rubber  gloves.  The 
rubber  sheet  is  sterilized  in  the  same  way  as  is  dry  catgut  and 
can  be  procured  in  the  market  done  up  in  sterile  packages  ready 
for  use.  After  the  skin  is  prepared  the  rubber  is  slightly  moist- 
ened with  ether,  rendering  a  minute  section  of  the  diameter  of 
the  rubber  fluid,  it  is  then  stretched  over  the  skin  with  consider- 


ATTIRE     OF     PATIENT  53 

able  traction  and  put  in  place.  The  rubber  immediately  adheres 
closely  to  the  skin  and  prevents  the  invasion  of  the  wound  by  in- 
fective substances.  The  incision  is  made  through  the  rubber,  and 
when  repair  is  made  the  sutures  are  taken  through  it.  At  last 
the  rubber  is  lifted  at  one  end,  and  after  incising  it  where  the 
sutures  penetrate  it,  removed. 

The  rubber  dam  is  not  affected  by  antiseptic  solutions  used 
during  the  operation,  and,  being  more  elastic  than  the  skin,  does 
not  interfere  with  free  manipulations  of  the  part.  In  cases  where 
suppurative  discharges  are  prolonged,  or  in  cases  subjected  to 
colostomy  or  cholecystotomy,  or  in  the  presence  of  fistulse  of  vari- 
ous kinds,  the  dam  may  be  used  over  a  considerable  period  of  time 
and  replaced  at  intervals  to  allow  of  cleansing  of  the  skin  beneath. 

ATTIRE   OF   PATIENT   ABOUT   TO   BE   REMOVED   TO 
OPERATING   ROOM 

The  attire  of  patients  about  to  be  subjected  to  operation  should 
be  arranged  to  render  accessible  the  part  to  be  attacked,  with  a 
minimum  of  exposure  of  the  rest  of  the  body,  and  at  the  same 
time  protect  the  patient  from  undue  exposure  to  either  cold  or 
heat. 

The  former  propositon,  i.e.,  protection  from  cold,  is,  as  a  rule, 
carefully  taken  care  of.  The  latter,  however,  is  perhaps  too  fre- 
quently disregarded.  It  is  to  be  remembered  that  heat  stroke  may 
occur  as  the  outcome  of  neglect  of  precautions  in  this  regard. 
When  the  abdomen  is  opened  the  general  rule  is  to  prevent  con- 
tact with  cold  air  on  the  part  of  the  contents  of  the  abdomen.  This 
is  obviously  a  correct  principle.  Yet  the  writer  cannot  help  but 
feel  that  a  patient  covered  in  part  by  impervious  rubber  sheeting, 
layers  of  woolen  blankets  to  absorb  irrigating  fluids,  sterile  sheet, 
and  layers  of  sterile  towels,  together  with  immediate  contact  with 
three  or  more  adults  who  surround  the  operating  table  in  various 
capacities,  is  getting  about  as  much  heat  as  is  necessary,  if  not 
more. 

A  glance  at  the  bluish  face,  with  little  streams  of  sweat  run- 
ning down  the  neck  of  a  narcotized  patient  should  sound  a  warn- 
ing in  this  connection.  Especially  is  this  true  in  operating  rooms 
where  the  apparatus  for  the  sterilization  of  instruments  and  uten- 


54 


PREPARATION   OF   THE   PATIENT 


sils  is  located  in  the  operating  room.  The  necessity  for  having 
available  means  of  rapid  sterilization  of  instruments,  etc.,  during 
an  operation  will  be  gone  into  more  extensively  under  a  separate 
head,  yet  mention  of  the  proposition  in  this  connection  seems 
proper. 

The  writer  has  seen  cases  of  exceedingly  high  temperature  im- 
mediately following  operations,  with  some  delirium  and  rapid 
pulse,  which  have  aroused  alarm  and  caused  some  confusion  as  to 
diagnosis.  The  fact  that  the  temperature  was  readily  reduced  with 
cold  applications,  and  that  no  subsequent  evidence  of  infection 
appeared,  seemed  to  justify  the  belief  that  the  disturbance  was 
due  to  heat  stroke.  Indeed,  in  the  summer  service  at  the  large 
hospitals  the  standardization  of  postoperative  fever  is  slightly  at 
variance  with  what  obtains  during  the  other  seasons.  A  tempera- 
ture of  103°  F.  immediately 
following  an  operation  does  not 
arouse  much  alarm  unless  it 
persists  into  the  second  or  third 
day. 

As  a  rule,  the  temperature 
of  the  sick  room  or  hospital 
ward  should  be  such  as  to  per- 
mit of  disrobing  the  patient 
without  the  occurrence  of  chilly 
sensations.  This,  as  stated, 
should  be  about  72°  F.  Dur- 
ing convalescence  the  tempera- 
ture of  the  sick  room  may  be 
lowered  to  68°  F.  However, 
the  general  notion  of  comfort 
in  disrobing  is  a  good  standard 
to  go  by.  Ordinarily  a  patient 
should  be  able  to  disrobe  in  a 
ward  or  sick  room  without  feel- 
ing cold.  The  artificial  meth- 
ods of  producing  heat  should 
be  so  regulated  as  to  permit  of 
this  and  at  the  same  time  allow 

Fig.  15. — Patient    Attired    for    Con- 
veyance to  Operating  Room.  01  free  ventilation. 


ATTIRE   OF   PATIENT  55 

Of  course,  this  is  not  an  easy  problem,  yet  if  the  room  be  kept 
at  70°  F.  and  the  ventilation  arrested  during  the  dressing  of 
wounds,  scrubbing,  etc.,  and  then  immediately  therafter  the  ven- 
tilation be  reestablished,  the  desirable  result  is  obtained. 

Before  removal  to  the  operating  room  the  hair  is  wrapped  in 
a  sterilized  towel.  A  short  shirt,  also  sterilized,  is  put  on  and  fas- 
tened behind  with  a  single  button  at  the  neck.  This  permits  of 
change  of  garment  immediately  after  operation  with  a  minimum 
of  disturbance  of  the  patient.  The  legs  are  encased  in  long  linen 
stockings,  which  have  also  been  sterilized.  Of  course,  these  gar- 
ments are  not  sterile  when  the  patient  reaches  the  operating  table. 
However,  they  should  be  sterilized  before  being  applied,  on  the 
ground  that  this  lessens  the  quantity  of  fertilizing  substances  in 
contact  with  the  patient.  Fig.  15  shows  a  patient  attired  as 
described. 


CHAPTER    III 

STERILIZATION   AND   PREPARATION    OF   INSTRU- 
MENTS AND    DRESSINGS 

Sterilization  of  instruments — General  sterilization — Steam  dressing  sterilizers 
— Requisites  for  a  major  operation. 


STERILIZATION    OF    INSTRUMENTS 

All  surgeons  agree  that  boiling  is  the  safest  and  most  simple 
method  of  sterilizing  instruments.  Instruments  to  be  rendered 
sterile  should  be  boiled  for  twenty  minutes.  The  apparatus  used 
for  the  purpose  varies  in  character  with  the  conditions  under  which 
the  operation  is  to  be  done.     The  elaborate  nickel-plated  boilers 


Fig.  16. — Instrument  Sterilizer  Suitable  for  Hospital  or  Surgeon's  Office. 

in  use  in  hospitals  and  in  surgeons'  offices,  while  desirable,  are 
not  essential  to  the  end  in  view.  Several  kinds  of  apparatus  for 
the  purpose  are  shown  in  the  accompanying  cuts  (-Figs.  16  and 
17).  _ 

Fig.  16  shows  an  apparatus  which  is  exceedingly  useful  and 

56 


STERILIZATION   OF   INSTRUMENTS 


57 


very  largely  used.  It  is  made  of  heavy  copper,  tinned  inside  and 
nickel  plated  outside,  with  a  detachable  bottom  tray  which  per- 
mits of  removal  of  the  instruments  without  disturbing  the  boiler. 
This  particular  boiler  is  fitted  with  a  gas  Bunsen  burner,  but  the 
same  apparatus  is  obtainable  furnished  with  either  alcohol,  petro- 
leum or  electric  heating  attachments. 

Fig.  17  shows  practically  the  same  apparatus,  except  that  there 
is  no  burner  attachment,  and  this  may  be  employed  either  with 
an  alcohol  flame  or  set  directly  upon  a  stove.  For  the  latter  pur- 
pose the  legs  are  detachable.     This  apparatus  is  useful  for  con- 


Fig.  17. — Portable  Instrument  Sterilizer,  with  Detachable  Legs. 


veying  to  the  scene  of  operation  instruments,  which  may  then  be 
sterilized  by  boiling  as  circumstances  demand,  in  accordance  with 
the  source  of  heat  available.  This  illustration  shows  the  perforated 
tray,  which  permits  of  the  easy  removal  of  the  instrument.  The 
tray  is  lifted  by  the  handles  shown,  which  are  turned  inward  when 
the  lid  of  the  boiler  is  closed. 

Both  of  these  boilers  are  very  useful  and  contribute  much  to 
the  facility  with  which  instruments  are  sterilized.  Yet  it  is  to  be 
understood  that  they  are  not  by  any  means  essential  to  complete 
and  thoroughly  effective  sterilization. 

The  method  of  procedure  consists  of  exposing  the  instruments 
to  a  temperature  of  212°  F.  for  twenty  minutes.  The  instruments 
are  placed  in  the  removable  perforated  tray,  and  after  this  has  been 


58      STERILIZATION   AND   PREPARATION   OF   INSTRUMENTS 

lowered  into  the  sterilizer  they  are  submerged  in  a  solution  of 
sodium  carbonate  or  borax  (2  per  cent.)  and  boiled. 

It  is  readily  seen  that  the  object  may  be  accomplished  by  any 
apparatus  which  will  hold  water  and  stand  heat.  A  fish  boiler, 
or  even  an  ordinary  saucepan  found  in  any  household,  is  as  ef- 
fective for  the  purpose  as  the  more  elaborate  sterilizers  described. 
However,  it  is  to  be  remembered  that  water  and  nickeled  instru- 
ments have  certain  incompatibilities  and  that  a  rusty  instrument 
is  exceedingly  objectionable. 

Tor  this  reason  the  soda  or  borax  are  added  to  the  water,  the 
theory  being  that  as  the  instruments  are  withdrawn  from  the  ster- 
ilizer the  soda  crystallizes  on  their  surface  and  in  the  joints  of  the 
instruments,  and  absorbs  the  last  few  drops  of  water  which  may 
remain  in  contact  with  them.  Thus  rusting  is  prevented.  This 
is  a  plea  for  an  apparatus  which  permits  of  the  withdrawal  of  the 
instruments,  together  with  the  containing  tray,  allowing  of  quite 
complete  drainage  of  the  water. 

It  is  worthy  of  note  that  the  impurities  in  tap-water,  such  as 
the  lime,  salts,  combined  with  other  foreign  substances,  held  in  solu- 
tion in  the  water,  cling  to  the  instruments,  and  cause  discoloration. 
Pure  water  is  not  likely  to  cause  discoloration  of  the  instruments. 
Also,  chemically  pure  soda  or  borax  should  be  used,  as  these,  too, 
cause  discoloration  if  impure. 

An  objection  to  the  boiling  of  instruments  is  the  fact  that  ex- 
cessive heat  destroys  the  edge  of  cutting  instruments.  It  is,  of 
course,  feasible  to  boil  all  other  instruments  and  subject  cutting 
instruments  and  needles  to  chemical  sterilization.  This,  however, 
is  expensive  and  slow  and  by  no  means  as  certain  as  heat. 

The  sterilization  of  instruments  with  smooth  surfaces  is  read- 
ily accomplished  by  immersion  in  pure  carbolic  acid  for  twenty 
minutes,  followed  by  lavage  with  alcohol,  the  latter  removing  the 
carbolic  acid  most  efficiently.  Lysol,  which  contains  some  soap, 
is  largely  used  for  the  purpose  and  is  effective.  It  also  permits  of 
subsequent  exposure  to  irrigating  fluids  with  less  damage  to  the 
instrument  than  the  former  method.  It  is,  however,  not  as  cer- 
tainly effective  as  the  carbolic  acid-alcohol  method. 

Mercury  destroys  instruments.  Contact  with  this  agent  should 
be  avoided  when  feasible,  though  this  is,  of  course,  impracticable 
when  corrosive  sublimate  solutions  are  used  as  an  irrigation  dur- 


STERILIZATION   OF   INSTRUMENTS 


59 


ing  the  operation.  Recently  a  preparation  of  mercuric  iodid  has 
come  on  the  market  which  seems  to  have  no  deleterious  effect  upon 
instruments.  It  is  used  in  solution  of  1  in  1000,  and  the  instru- 
ment should  be  submerged  for  twenty  minutes.  In  this,  as  in 
other  instances,  pure  water  should  be  used. 

Grosse  of  Munich  has  devised  a  method  of  heat  sterilization 
for  knives  which  seems  to  be  of  value  and  does  not  cause  rusting. 


Fig.  18.— Glass  Tube  with  Knives  for  Steam  Sterilization. 


..■.-^  j 


The  knives  are  placed  in  a  metal  rack  (Fig.  18),  which  is  slipped 
into  a  glass  tube  provided  with  a  stopper.  The  entire  tube,  after 
being  closed,  is  placed  in  an  ordinary  steam  pressure  sterilizer 
(page  62)  and  treated  as  described  under  the  head  of  dressing 
sterilization. 

For  the  purpose  of  sterilizing  a  single  knife,  a  smaller  rack 
and  glass  tube    (Fig.    19)    may  be  used.      The 
knife  is  held  securely  by  the  metal  wire  suitably  O 

bent  for  the  purpose,  so  as  to  protect  the  edge. 
The  tube  is  closed  by  absorbent  cotton  used  as  a 
stopper.  After  exposure  to  steam  for  ten  min- 
utes the  knife  is  absolutely  sterile,  and  no  specks 
are  visible  on  it. 

Traces  of  condensed  steam  are  observable  in- 
side the  tube  upon  the  glass,  which,  however,  dis- 
appear rapidly  after  the  tube  is  withdrawn  from 
the  apparatus.  This  is  explained  on  the  ground 
that  steam  generated  from  the  small  quantity  of 
hygroscopic  water  contained  in  the  atmospheric 
air  inclosed  in  the  glass  container  always  preci- 
pitates upon  the  glass,  which  is  specifically 
colder,  and  not  on  the  steel,  which  has  a  larger 
capacity  for  heat. 

If  it  is  desirable  to  sterilize  a  number  of  knives  each  in  a  sepa- 


Fig.  19.  —  Single 
Knife  in  Glass 
Tube  Ready  for 
Steam  Pressure 
Sterilization. 


60      STERILIZATION   AND   PREPARATION   OF   INSTRUMENTS 


rate  container  for  each  operation,  a  number  of  tubes  arrayed  as 
described  may  be  conveniently  placed  in  a  rack,  as  shown  in  Fig. 

20.  This  would  seem 
to  involve  less  danger 
of  contamination  dur- 
ing handling  than  if 
the  four  knives  are 
simultaneously  placed 
in  one  rack  and  larger 
glass  tube. 


GENERAL    STERILI- 
ZATION 

In  well-equipped 
hospitals  all  material 
coming  in  contact  with 


-SCHEEfiEfi  CajtV. 


Fig.  20. — Rack  for  Holding  Knives  in  Sepa- 
rate Containers,  Ready  for  Steam  Pres- 
sure Sterilization. 


the  patient  is  sterilized 
by  heat.  Here  is  undoubtedly  the  most  effective  agent  for  the 
sterilization  of  gowns,  towels,  dressings,  etc.,  used  in  surgical 
technic;  yet  it  is  not  at  all  times  applicable  to  the  varying  con- 
ditions under  which  operations  have  to  be  undertaken.  In  the 
latter  instances  chemical  sterilization  is  a  necessity,  and,  it  may 
be  said,  if  patiently  and  carefully  carried  out,  is  as  effective  as 
heat. 

Of  course  a  judicious  combination  of  heat  and  chemical  steril- 
ization, together  with  mechanical  cleansing,  is  almost  always  ob- 
tainable— i.e.,  towels  may  be  boiled  and  even  gowns  may  be  boiled 
and  put  on  wet  in  case  of  necessity.  Yet,  if  it  be  feasible,  steam 
heat  should  be  used  for  the  purpose,  as  it  renders  them  sterile  and 
more  readily  handled. 

The  most  desirable  method  of  sterilization  will  be  taken  up 
first,  and  then  the  modifications  necessary  because  of  absence  of 
the  desirable  apparatus  will  be  discussed. 

The  principle  underlying  the  sterilization  of  all  material  com- 
ing in  contact  with  operative  wounds  is  the  outcome  of  the  dis- 
coveries of  Pasteur  made  known  in  1879.  The  relationship  which 
bacteria  bear  to  infection  was  first  demonstrated  by  this  indefat- 
igable worker.    The  researches  of  Koch  and  Wolfhuegel  are  based 


GENERAL   STERILIZATION  61 

upon  the  observations  made  known  by  Pasteur.  Sterilization  by 
heat  is  the  outcome  of  the  experimentation  of  the  two  former 
observers. 

The  first  attempt  to  destroy  pathogenic  substances  was  made 
by  D arrow  and  Symington,  two  English  physicians,  who,  in  1850, 
subjected  the  clothing  of  cholera  patients  to  dry  air  at  a  tempera- 
ture of  220°  to  250°  F.  by  baking  in  a  crude  oven.  The  measure 
was  exceedingly  effective. 

Although  various  physical  agents,  such  as  heat,  cold,  light,  and 
dryness,  possess  power  to  destroy  bacteria,  heat  is  the  most  ef- 
fective agent,  and  the  one  most  readily  obtained  and  controlled 
for  the  purpose.  Sunlight  and  certain  concentrated  forms  of  arti- 
ficial light  are  capable  of  destroying  bacteria,  yet  the  process  neces- 
sary to  accomplishing  the  desired  end  is  a  prolonged  one,  and  by 
no  means  as  certainly  effective  as  heat. 

Cold  is  a  feeble  bactericidal  force.  Frost,  which  has  been  so 
generally  regarded  as  destructive  to  malarial  and  yellow  fever 
poisons,  is  now  believed  to  destroy  only  the  carriers  of  infection — 
i.e.,  the  mosquito — and  leave  the  infecting  agent  unharmed. 

Dryness  destroys  the  cholera  germ,  but  is  a  condition  favorable 
to  the  growth  and  life  of  bacteria  generally. 

Dry  heat  will  destroy  bacteria.  It  requires  a  temperature  of 
150°  to  165°  C.  to  accomplish  the  object,  and  the  exposure  must 
continue  for  one  hour. 

Moist  heat  at  a  temperature  of  100°  C.  will  destroy  all  bac- 
teria and  spores  in  a  few  minutes. 

This  should  be  borne  in  mind  in  instances  where  steam  heat  is 
not  available  for  sterilization  and  baking  of  dressings,  etc.,  if  an 
oven  is  used  for  the  purpose.  Steam  and  air  have  certain  molec- 
ular antagonism  in  a  given  area,  until  there  is  an  equalization 
of  the  difference  in  expansion  in  these  two  bodies.  This  accounts 
for  the  peculiar  inequality  of  action  of  apparatus  for  sterilization 
which  does  not  allow  of  the  removal  of  air  from  the  sterilization 
apparatus  before  the  steam  is  forced  in. 

The  potency  of  steam  heat  in  destroying  ineffective  organisms 
depends  upon  the  temperature.  While  it  is  true  that  anthrax  spores 
will  be  destroyed  by  a  temperature  of  90°  C.  in  twenty  minutes, 
only  five  minutes  of  exposure  to  a  temperature  of  95°  C.  is 
required. 


62      STERILIZATION   AND   PREPARATION   OF   INSTRUMENTS 


The  thermal  death  point  of  bacteria  bears  a  certain  relation- 
ship to  the  coagulability  of  albumin.  When  albumin  containing 
bacteria  is  in  solution,  or  in  a  moist  state,  it  requires  comparatively 
little  heat  to  destroy  them.  On  the  other  hand,  if  the  albumin 
culture  medium  is  dried,  it  will  withstand  a  high  degree  of  tem- 
perature for  a  long  time.     When  moist  heat  at  100°  C.  comes  in 

contact  with  a  spore  it  is 
killed  just  as  soon  as  it 
absorbs  enough  moisture 
to  allow  of  coagulation. 

A  sterilizer,  then,  to 
accomplish  the  purpose 
most  readily  and  thor- 
oughly, should  be  so  con- 
structed as  to  achieve  the 
following:  elimination  of 
air  from  the  sterilization 
chamber,  the  penetration 
of  the  objects  with  steam 
fully  saturated,  the  pre- 
vention of  condensation 
of  water  on  the  objects. 

STEAM    DRESSING 
STERILIZERS 

In  large  institutions 
where  steam  power 
plants  are  constantly  in 
operation  for  the  pur- 
pose of  furnishing  heat, 
power  and  light,  steam  is 
readily  available,  and  is 
led  into  the  outer  jacket 
of  the  steam  sterilizer  by 
the  means  of  pipes  which 
coil  in  the  outer  water 
jacket  and  heat  the  water  to  the  desired  temperature.  However, 
in  most  instances,  this  condition  of  affairs  is  not  available,  and  the 


Fig.  21. — Steam  Pressure  Sterilizer  for 
Dressings,  Etc. 


STEAM   DRESSING   STERILIZERS 


63 


water  in  the  outer  jacket  is  heated  by  means  of  a  gas  Binnen 
burner  placed  beneath  the  apparatus. 

As  a  matter  of  fact,  it  makes  no  difference  from  which  source 
the  heat  is  obtained,  as  long  as  it  is  of  sufficient  quantity  to  de- 
velop the  temperature  re- 
quired for  sterilization. 
Oil,  alcohol,  etc.,  are  as 
effective  in  this  regard  as 
coal  or  illuminating  gas. 
Electricity,  while  effective, 
is  expensive  and  requires 
much  time  to  produce  the 
necessary  temperature, 
though  ideal  in  cleanliness 
and  elasticity  of  applica- 
tion. For  the  purpose  of 
this  work,  it  is  sufficient 
to  describe  the  apparatus 
usually  employed  with  a 
gas  Bunsen  burner.  A 
complete  description,  to- 
gether with  illustration 
(Figs.  21  and  22),  is  given. 

1.  Fill  the  steam  jacket 
with  clear  water  by  open- 
ing valve  on  metal  funnel 
C,  turning  lever  No.  1  to 
the  right.  The  quantity  of 
water  required  for  steriliza- 
tion depends  on  the  length 
of  time  for  which  the  ap- 
paratus shall  be  operated. 
It  is  not  desirable  to  have 

the  jacket  filled  more  than  half  full  of  water  (see  sectional  view, 
Fig.  22).  The  glass  water  gauge  on  side  indicates  exactly  the 
height  of  water  jacket. 

2.  A  permanent  connection  with  the  hydrant  water  supply  can 
be  made  through  valve  "  G  "  (the  clean-out  valve)  by  connecting 


Fig.  22. — Sectional  View  op  Steam  Pres- 
sure Sterilizer  Shown  in  Fig.  21. 


64       STERILIZATION   AND   PREPARATION   OF   INSTRUMENTS 

a  Tee  back  of  valve  "  G  "  and  using  a  gate  valve  on  the  Tee,  to 
which  you  connect  your  hydrant  water.  This  method  of  filling 
the  water  into  the  jacket  works  rapidly,  and  in  addition  offers  the 
advantage  to  be  able  to  inject  water  at  any  time  even  though  the 
apparatus  may  be  under  pressure  and  in  operation.  The  pressure 
of  the  water  supply  at  point  of  entrance  at  valve  "  G  "  must,  of 
course,  exceed  that  of  the  steam  pressure  in  the  jacket ;  the  latter 
being  fifteen  pounds  per  square  inch,  it  follows  that  the  water  pres- 
sure should  at  least  be  twenty-five  pounds  or  more. 

3.  The  steam  jacket  having  been  filled  with  a  sufficient  quan- 
tity of  water,  throw  lever  handle  ISTo.  1  back  to  the  left  and  light 
the  burner  (gas,  petroleum  or  alcohol)  leaving  valve  on  funnel  0 
open  until  steam  issues,  then  close  it  tightly.  The  combination 
steam  pressure  and  vacuum  gauge  E  will  register  the  conditions 
prevailing  in  the  jacket  and  the  steam  pressure  safety  valve  D  will 
blow  off  steam  as  soon  as  the  latter  exceeds  the  normal  pressure  of 
fifteen  pounds  (=  1  Atmosphere). 

4.  The  dressing  material  should  be  placed  into  the  sterilizer 
chamber  before  the  heaters  are  lit  or,  as  in  the  case  of  steam- 
heated  jackets,  before  the  boiler  steam  is  turned  into  the  heating 
coils.  Door  of  sterilizer  is  locked  securely  and  air  filtering  cup 
valve  F,  which  is  filled  with  a  wad  of  absorbent  cotton,  is  left 
open,  handle  being  in  vertical  position  as  shown  in  drawing,  Fig. 
22. 

Gradually  as  the  temperature  of  the  water  in  jacket  increases, 
the  air  in  the  sterilizer  chamber  becomes  rarefied  and  finds  an 
escape  through  cup  valve  F.  The  sterilizer  chamber,  therefore, 
in  the  first  stage  of  the  process  serves  the  purpose  of  a  hot-air 
oven,  gradually  warming  the  dressings  preparatory  to  letting  pres- 
sure steam  into  the  chamber. 

5.  As  soon  as  the  combination  steam  and  vacuum  gauge  E 
indicates  a  steam  pressure  of  fifteen  pounds,  the  safety  valve  will 
begin  to  operate  by  blowing  off  steam  in  excess  of  the  required 
pressure,  then  close  the  air  filtering  cup  valve  F  by  thrusting 
handle  into  a  horizontal  position. 

The  moment  has  now  arrived  for  exhausting  the  already  rare- 
fied air  in  the  sterilizer  chamber  by  creating  a  partial  vacuum. 
This  is  done  by  opening  valve  ~No.  2  on  the  steam  exhaust  pipe 


STEAM   DRESSING   STERILIZERS  65 

and  by  throwing  lever  No.  1  to  the  right.  The  combination  gauge 
E  will  soon  register  a  vacuum  in  the  chamber,  five  inches  being 
sufficient  to  insure  absolute  results. 

When  this  degree  of  vacuum  has  been  reached,  close  valve  No. 
2  whereupon  the  pressure  steam  will  rush  into  the  chamber.  The 
dressing  material  contained  in  the  latter,  having  thus  been  care- 
fully prepared  by  the  air  exhaust  process  for  an  eager  absorption 
of  live  steam,  will  instantaneously  and  thoroughly  be  penetrated 
by  the  same.  Furthermore,  since  the  inrushing  steam,  which  is 
of  a  temperature  of  250°  F.  (121°  C.)  will  meet  with  material 
which  has  for  some  time  been  subjected  to  dry  hot  air  of  nearly 
the  same  degree  of  temperature  as  that  of  the  pressure  steam,  the 
latter  will  not  condense,  and  therefore  not  wet  the  dressings.  The 
process  of  steam  sterilization  shall  last  from  twenty  to  thirty 
minutes. 

6.  The  dressing  material  can  now  be  considered  absolutely 
sterile,  and  may  be  taken  out  at  once  if  desired.  It  is  advisable, 
however,  to  let  it  remain  in  the  sterilizer  chamber  for  from  ten 
to  twenty  minutes  longer  in  order  to  remove  every  trace  of  damp- 
ness. For  this  purpose  open  valve  No.  2,  and  again  start  the  ex- 
hausting process  described  under  No.  5,  for  the  time  above  speci- 
fied. After  this,  extinguish  flame  or  shut  off  steam  supply,  close 
valve  No.  2  and  throw  lever  No.  1  to  the  left. 

7.  To  remove  sterilized  dressings  from  the  chambers,  it  is 
necessary  to  destroy  the  vacuum  in  the  latter  in  order  to  be  able 
to  open  the  door.  This  is  done  by  letting  air  enter  the  chamber 
through  the  air  filtering  cup  valve  F,  which  is  filled  with  absorbent 
cotton. 

Dressings  thus  prepared  can  be  absolutely  depended  upon  as 
to  their  sterility.  They  may  be  left  in  the  apparatus  for  an  in- 
definite time  before  being  used  without  becoming  infected. 

The  noise  made  by  the  blowing  off  of  the  steam  in  creating  the 
partial  vacuum  is  exceedingly  annoying.  This  may  be  overcome 
by  leading  the  blow  off  by  means  of  a  steel  pipe  into  the  open  air  at 
some  convenient  place  near  the  apparatus. 

Of  course,  the  handling  of  the  material  subjected  to  these  meas- 
ures is  performed  by  a  person  whose  hands  are  not  sterile.  Con- 
sequently, the  material  must  be  placed  in  an  outer  container  which 
will  allow  of  handling  without  contact  with  non-sterile  substances. 


66      STERILIZATION   AND   PREPARATION   OF   INSTRUMENTS 

For  this  purpose  the  gowns,  wipes,  towels,  etc.,  are  enclosed,  in  con- 
venient quantities,  in  muslin  wraps,  and  these  opened  at  the  time 
of  operation  by  an  attendant  who  is  definitely  detailed  to  the  work 
of  handling  all  material  between  the  sterilizer  and  those  coming  in 
contact  with  the  wound. 

Indeed,  at  all  operations  one  such  person  is  in  attendance  for 
the  purpose  of  handling  the  solutions,  changing  the  posture  of  the 
patient,  etc.,  and  this  portion  of  the  work  may  be  done  by  this 
person.  This,  however,  will  be  more  largely  taken  up  under  the 
head  of  operating  room  teclmic. 

The  expense  of  the  apparatus  described  is  not  so  great  as  to 
be  an  important  factor  in  causing  the  adoption  of  simpler  means 
of  heat  sterilization.  However,  the  object  can  be  obtained  by  the 
use  of  apparatus  which  is  less  expensive  and  less  complicated.  In 
view  of  the  fact  that  all  dressing  material,  towels,  wipes,  etc.,  may 
be  sterilizecl  and  packed  in  air-tight  packages  and  kept  for  a  long 
period  of  time,  it  is  suggested  that  the  surgeon  had  best  draw  upon 
some  central  plant  for  the  material  mentioned,  rather  than  rely 
upon  means  which  involve  modification  of  the  principles  here 
laid  down. 

'  Indeed,  it  has  been  found  that  thoroughly  reliable  material 
may  be  obtained  from  commercial  houses  which  prepare  dress- 
ings, gowns,  sheets,  etc.,  which  are  necessary  for  a  given  opera- 
tion, place  the  entire  outfit  in  a  convenient  box,  and  are  prepared 
to  ship  the  same  to  the  surgeon  or  the  patient's  house  at  short 
notice. 

REQUISITES   FOR   A   MAJOR    OPERATION 

A  specimen  outfit  is  here  described.  This  particular  outfit  is 
designed  to  be  used  for  celiotomy,  and  can  be  readily  modified  to 
meet  the  indications  of  most  any  surgical  contingency  which  may 
arise. 

The  list  given  here  is  an  elaborate  one,  and  is  elastic  in  the 
sense  that  successful  work  may  be  done  with  less  material,  though, 
as  a  general  rule,  it  is  best  to  err  on  the  side  of  safety.  Again,  if 
the  surgeon  is  in  a  position  to  resterilize  material  left  unused, 
nothing  has  been  lost.  Indeed,  it  is  suggested  that  the  surgeon 
furnish  himself  with  an  outfit  as  described  which  will  form  the 
basis  of  his  stock  on  hand  and  act  as  a  guide  in  this  regard , 


REQUISITES  FOR  A  MAJOR  OPERATION  67 

The  list  does  not  include  suture  material,  which  is  taken  up 
under  separate  head. 

2  four-quart  white  enamel  pitchers. 

1  two-quart  white  enamel  pitcher. 

4  white  enamel  basins. 

1  gown  for  self  and  each  assistant  and  nurse. 

1  cap  for  self  and  each  assistant  and  nurse. 

1  pair  armlets  for  self  and  each  assistant  and  nurse. 

2  pair  rubber  gloves  for  self  and  each  assistant  and  nurse. 
4  demijohns  of  sterilized  and  distilled  water. 

6  oz.  tinct.  green  soap. 

3  sterilized  nail  brushes. 

3  sterilized  orange  wood  sticks. 

3  bone  nail  cleaners. 

1  bottle  of  chlorinated  lime  (8  oz.). 

1  bottle  soda  carbonate  (granular  8  oz.). 
3  dozen  sterilized  gauze  pads  with  tapes. 
6  dozen  sterilized  wipes. 

3  sterilized  celiotomy  rolls. 

2  packets  sterilized  absorbent  gauze  (5  yards  each). 

1  pound  sterilized  absorbent  cotton. 

3  tubes  iodoform  gaiize,  5  yards  by  6  inches. 

3  tubes  plain  sterilized  gauze,  5  yards  by  2^  inches. 
3  sterilized  combined  dressings. 

2  sterilized  binders  (many  tailed). 

1  sterilized  T  binder. 

3  cigarette  drains. 

2  rubber  tube  drains. 

3  bottles  bichlorid  of  mercury  tablets. 
1  bottle  carbolic  acid  (6  oz.). 

1  box  boracic  acid. 

2  dozen  bottles  sterilized  salt. 

4  dozen  sterilized  cotton  towels  (soft). 
1  dozen  sterilized  vulvar  pads. 

1  tube  of  sterile  lubricant. 

1  sterilized  self-retaining  catheter  No.  16  French. 
1  sterilized  self-retaining  catheter  No.  20  French. 
1  sterilized  glass  catheter. 


68       STERILIZATION  AND   PREPARATION   OF  INSTRUMENTS 

1  bath  thermometer. 

1  rectal  tube. 

1  four-quart  sterilized  douche  bag  and  glass  nozzle. 

1  roll  2-inch  adhesive  plaster. 

1  celiotomy  sheet. 

2  sterilized  rubber  sheets. 

Hypodermic  tablets,  strych.,  morph.,  and  nitroglycerin. 
Duck  suits  and  canvas  shoes  for  surgeon  and  assistants. 

The  four-quart  pitchers  are  filled  with  cleansing  solutions, 
one  with  an  antiseptic,  usually  bichlorid  of  mercury,  the  other 
with  saline  solution.  The  two-quart  pitcher  is  used  for  replen- 
ishing the  larger  two  as  the  necessity  arises.  The  pitchers  are 
sterilized  by  boiling  or  by  thorough  lavage  and  subsequent  im- 
mersion in  bichlorid  of  mercury  solution.  After  being  filled,  they 
are  covered  with  a  sterile  towel  (Fig.  70). 

In  the  edge  of  the  folded  towel  a  safety  pin  is  fastened  allow- 
ing of  lifting  of  the  towel  (Fig.  71)  by  the  non-sterile  nurse,  who 
pours  the  sterile  contents,  as  shown  in  Fig.  71,  without  contami- 
nating them.  A  serviceable  arrangement  of  pitchers  is  shown  in 
Fig.  70. 

The  enameled  basins  are  sterilized  in  the  same  manner  as 
the  pitchers,  and  are  used  for  solutions  employed  for  cleansing 
the  hands  of  surgeons  and  assistants  (Fig.  76). 

Gowns  should  be  of  ample  size  and  arranged  to  be  fastened 
with  tapes  at  the  back  of  the  wearer.  Though  the  forearm  is 
cleansed  before  operating,  it  is  best  to  cover  it  with  sterile  fabric. 
For  the  purpose,  gowns  with  long  sleeves,  as  shown  in  Fig.  86, 
or  a  similar  gown  with  short  sleeves  and  detachable  armlets,  may 
be  employed.  The  advantage  of  the  latter  is  that,  when  the 
sleeves  become  soiled  during  an  operation,  they  can  be  quickly 
changed  without  disturbing  the  gown.  The  sleeves  of  the  gowns 
worn  by  the  assistants  who  do  not  come  in  contact  with  the  wound 
may  be  long,  and  will  not  require  changing  during  the  operation. 

Caps. — The  object  of  the  cap  is  to  prevent  the  falling  of  hair 
and  impurities  from  the  scalp  into  the  wound  or  upon  the  ma- 
terial coming  in  contact  with  the  patient.  While  aseptic  results 
are  common  when  this  precaution  is  not  taken,  it  is  best  to  em- 
ploy the  additional  measure  of  safety.     The  surgeon  and  assist- 


REQUISITES   FOR  A  MAJOR  OPERATION  69 

ant  should  wear  a  mask  and  cap  combined  (Fig.  8-4).  This  pre- 
vents contamination  from  beard,  mouth,  and  perspiration. 

In  operative  work  done  in  public  clinics  where  the  operator 
lectures  during  the  operation,  this  is  slightly  objectionable.  How- 
ever, in  these  instances  the  mask  need  not  cover  the  lips,  and  the 
surgeon  may  take  the  precaution  to  turn  the  head  away  from  the 
wound,  while  speaking.  It  is  not  uncommon  to  see  perspiration, 
the  result  of  the  high  temperature  of  the  operating  room  or,  per- 
chance, of  certain  vasomotor  disturbances  due  to  emotional  causes, 
drip  into  the  wound.  This  should  be  avoided,  though  it  may  be 
said  that  after  prolonged  perspiration  the  sweat  washes  the  ex- 
cretory ducts  quite  free  from  contaminating  bacteria. 

The  mask  should  be  made  of  sufficient  thickness  and  of  suffi- 
ciently absorbent  material  not  to  require  changing  during  an 
operation. 

Rubber  gloves  are  either  boiled  and  slipped  on  wet  or,  per- 
haps better  yet,  boiled,  dried,  dusted  with  lycopodium,  packed  in 
gauze,  and  sterilized  under  pressure,  together  with  dressings  and 
gowns.  The  subject  of  gloves  is  taken  up  more  extensively  under 
the  head  of  cleansing  of  the  hands  (page  126).  The  gauntlets  of 
the  gloves  should  extend  over  the  cuffs  of  the  gown  (Fig.  82). 

The  sterilized  and  distilled  water  is  used  for  cleansing  and 
lavage.  It  is  more  desirable  to  have  the  water  distilled  to  remove 
all  foreign  bodies,  yet  water  may  be  sterilized  by  boiling.  One- 
half  the  water  on  hand  should  be  hot  and  the  other  cold.  Tap 
water  may  be  boiled  in  two  large  tin  receptacles,  covered  up,  and 
allowed  to  cool.  A  short  time  before  the  operation  one  of  the 
boilers  is  heated,  the  other  left  cold  to  allow  of  elasticity  in  the 
adjustment  of  temperature  during  the  operation. 

Soap  is  most  commonly  used  in  the  form  of  the  tincture  of 
green  soap.  This  is  employed  with  the  view  of  saponifying  the 
fat  on  the  skin.  It  is,  however,  a  wasteful  method,  as  much  of 
the  fluid  is  allowed  to  escape.  A  jar  of  green  soap  (Fig.  76)  is 
perhaps  as  useful  a  means  of  keeping  soap  as  any,  though  there 
is  no  objection  to  using  the  ordinary  laundry  soap   (Fig.  76). 

Nail  brushes  should  not  be  sufficiently  stiff  to  scratch  the 
hands.  They  are  boiled  and  placed  in  a  glass  jar  together  with 
the  orange  sticks  and  submerged  in  bichlorid  solution.  The  nail 
cleaners    are    also   boiled    and    placed,    together   with    the    soap, 


70      STERILIZATION   AND   PREPARATION   OF   INSTRUMENTS 

brushes,  and  lime  and  soda  containers,  on  a  suitable  table  near 
the  washstand  (Fig.  76). 

The  calcium  chlorid  is  placed  in  an  open  dish  and  the  sodium 
carbonate  in  a  similar  one.  These  dishes  are  of  white  enamel, 
and  are  placed  on  the  table  prepared  for  the  surgeon,  as  shown  in 
Fig.  TO.  The  method  of  use  is  taken  up  under  the  head  of  cleans- 
ing of  the  hands  (page  126). 


1 

i^ 

■, 

i 

f 

Fig.  23. — Gauze  Pad  with  Tape  axd  Forcipressure  and  Wipes  of  Two    Sizes. 


The  gauze  pads  are  prepared  as  follows :  Cut  gauze  in  squares 
12  inches  by  12  inches,  leaving  an  extra  margin  of  one-quarter 
of  an  inch  for  seam.  Place  three  of  these  squares  one  upon  the 
other  so  as  to  have  three  thicknesses  of  gauze.  Sew  around  the 
four  sides,  leaving  an  opening  at  one  corner  through  which  to 
turn  the  pad  inside  out,  so  that  the  frayed  edge  of  the  seam  is 
inside.     This  prevents  small  shreds  of  gauze  from  being  left  in 


Fig.  24. — Gauze  for  Making  Wipe. 


Fig.  25. — Gauze  Folded  Once. 

71 


72      STERILIZATION  AND   PREPARATION   OF   INSTRUMENTS 


the  wound,  which  act  as  foreign  bodies  when  this  precaution  is 
disregarded.  After  the  pad  is  turned  the  small  opening  at  one 
corner  is  finished  off  and  a  tape  6  inches  long  and  one-fourth  inch 
wide  is  attached  firmly  to  the  corner  last  closed,  so  as  to  have  all 


Fig.  26. — Gauze  Folded  Twice. 

stitching  at  one  place.  This  tape  is  intended  for  the  attachment 
of  forcipressure,  which  latter  hangs  out  of  the  wound,  so  that  the 
pad  may  not  be  lost  or  forgotten.  When  finished  the  pad  appears 
as  shown  in  Fig.  23. 

Six  of  these  pads  are  folded  in  a  gauze  wrapper,  then  in  a 

muslin  wrapper,  then 
labeled,  and  are  then 
ready  for  sterilization. 
The  wrapper  is  em- 
ployed in  hospital  prac- 
tice and  in  instances 
where  the   surgeon  has 

Fig.  27. — Gauze  Folded  One-third  of  Length. 

a  large  demand  for  the 
material.  In  private  practice,  however,  the  wrapper  may  be  re- 
placed by  any  convenient  container,  such  as  a  towel  or  a  paper 
box,  etc. 

Wipes  vary  in  size,  the  usual 
and  perhaps  most  universally  use- 
ful size  being  four  inches  square. 
The  description  here  is  that  of  the 
size  mentioned,  but  is  equally  ap- 
plicable to  other  dimensions.  Cut 
gauze  into  oblongs  12  inches  by 
16  inches  (Fig.  24),  fold  length- 
wise (Fig.  25),  fold  lengthwise  a 

a  second  time  (Fig.  26),  fold  one-third  of  length  (Fig.  27),  fold 
again  in  the  same  direction  (Fig.  28).     Take  in  right  hand  and 


Fig.   28. — Gauze     Strip     Folded 
Two-thirds  of  Length. 


REQUISITES  FOR   A   MAJOR   OPERATION 


73 


with  left  hand  take  the  outer  layer  of  gauze  at  open  end  (Fig. 
29),  and  turn  wipe  inside  out  (Fig.  30),  permitting  the  passage 
of  both  hands  through  the  one  side  (Fig.  31).  Turn  the  wipe 
and  repeat  the  turning  process  on  the  opposite  side,  allowing  of 
the  manipulation  shown  in  Fig.   32.      This  turns  in  all  frayed 


Fig.  29.— Manner    of    Holding    Folded    Gauze    Preliminary 
to  Inverting  Edges. 


edges.  Wipes  of  two  by  two  inches  are  treated  in  the  same  way. 
Fig.  23  shows  the  three  sizes  most  commonly  employed.  The 
packing  and  preparation  for  sterilization  is  similar  to  that  de- 
scribed under  pads  (page  72). 

Gauze  pads  are  used  to  pack  off  operation  fields  in  cavities. 

In  certain  instances,  however,  it  is  preferable  to  employ  long 


74      STERILIZATION   AND   PREPARATION   OF   INSTRUMENTS 

pieces  of  folded  gauze,  which  permit  of  greater  adaptability,  and 
also  involve  less  danger  of  being  left  behind.  For  the  purpose, 
gauze  two  yards  long  and  one  yard  wide  is  folded  on  itself 
lengthwise  three  times,  becoming  thus  four  inches  wide  and 
consisting  of  eight  layers.     The  gauze  is  then  rolled   (Fig.  33) 


Fig.   30. — Manner  of  Inverting  Folded  Gauze  Strip. 

and  treated  as  described  under  sterilization  of  pads.  At  times 
rolls  of  less  diameter  are  preferable.  To  attain  this  it  is  only 
necessary  to  reduce  the  size  of  the  original  piece  and  handle  as 
before. 

Two  packages  containing  each  five  yards  of  sterile  gauze  are 
prepared.  The  gauze  is  prepared  in  the  same  way  as  for  celiotomy 
rolls,  being  four  inches  wide  when  folded,  and  two  yards  in  length. 


REQUISITES  FOR  A   MAJOR   OPERATION 


75 


The  gauze  is  used  for  the  protective  dressing.  It  may  be  cut  into 
shorter  lengths  or  folded  more  narrowly  to  suit  the  necessities  of 
a  given  case. 

Sterilized  cotton  is  furnished  in  cartons  by  the  manufacturer, 
in  varying  quantities.     It  is  best  to  use  several  packages  of  small 


. 


Fig.  31. — -Gauze  Wipe  Completed.     Front  view,  showing  edges 
inverted. 


size  than  run  the  risk  of  contamination  in  using  larger  ones  on 
more  than  one  occasion. 

Gauze  for  dressings  and  packing  may  be  packed  in  tins  or  glass 
tubes.  Here  again  the  container  should  be  of  the  size  holding  a 
quantity  to  be  used  for  a  certain  case,  and  if  a  portion  of  the  gauze 
be  unused,  this  had  best  be  destroyed  and  a  new  container  used 


76      STERILIZATION  AND  PREPARATION   OF   INSTRUMENTS 

each  time.  Fig.  34  shows  a  desirable  form  of  glass  tube  container. 
Medicated  gauzes  are  not  as  largely  used  in  surgical  practice  as 
formerly.  The  two  kinds  most  commonly  employed  are  iodoform 
gauze  and  gauze  saturated  with  balsam  of  Peru. 


Fig.  32. — Wipe  Completed  (back  view). 


Iodoform  gauze  is  prepared  as  follows : 

Pulv.  iodoform oz.  vj. 

Glycerin    O.  j. 

Alcohol oz.  viij. 

Ether    oz.   viij. 

Place  iodoform  in  sterile  basin  carefully  and  completely  break 


REQUISITES  FOR  A  MAJOR  OPERATION  77 

up  lumps  with  sterile  spatula,  add  glycerin,  gradually  rubbing 
into  a  paste.  Add  alcohol  and  mix.  Add  ether  and  mix.  Roll 
gauze,  prepared  as  for  celiotomy  (Fig.  33),  in  mixture,  until  all 
ingredients  are  absorbed.      Place  in  layers  in  sterile  towel,  pin 


Fig.   33. — Gauze    Roll,    Suitable   for   Packing   Wounds 
and  Cavities. 

tightly.     Pack  in  oil  silk,  inclose  in  second  sterile  towel,  and  steri- 
lize.    The  gauze  may  be  cut  to  any  desired  size. 
Balsam  of  Peru  gauze  is  prepared  as  follows : 

Balsam  of  Peru O.  j. 

Glycerin   oz.  1. 

Mix  in  basin  and  treat  as  instructions  with  iodoform  gauze. 
A   combination  of  gauze  and  absorbent  cotton  is  a  desirable 


78      STERILIZATION   AND   PREPARATION   OF   INSTRUMENTS 

agent  for  the  protective  dressing.     It  is  absorbent,  and  the  cotton 
is  impermeable  to  bacteria. 

Combined  dressing  is  prepared  by  cutting  gauze  12  by  12 
inches.  A  layer  of  this  is  laid  flat  and  cotton  is  smoothly  laid 
on  it,  the  latter  being  made  smaller  than  the  gauze  so  as  to  permit 


Fig.  34. — Gauze   for   Packing   in    Glass   Container. 


of  overlapping  of  one  inch  all  around.  A  second  layer  of  gauze, 
similar  in  size  to  the  first,  is  placed  on  top  of  the  cotton  (Fig. 
35).    Six  of  these  dressings  are  placed  in  a  packet  and  sterilized. 

Fig.  36  shows  a  transverse  section  of  combination  dressing  cut 
squarely,  for  purposes  of  illustration,  with  the  scissors.  It  will 
be  noted  that  the  cotton  fills  the  space  between  the  two  layers  of 


Fig.  35. — Making  Combined   Dressing.      The  top  layer  of  gauze  is  being 
placed  in  contact  with  the  layer  of  cotton. 


Fig.  36. — Transverse  Section  of  Combined  Dressing. 


Fig.  37. — Many-tailed  Abdominal  Binder. 


79 


80      STERILIZATION  AND   PREPARATION   OF   INSTRUMENTS 


gauze,  which  are  quite  clearly  outlined  in  the  figure.     In  this  way 
a  smooth  surface  is  presented  for  the  retaining  bandage. 

The  many-tailed  hinder  is  made  of  heavy  muslin  or  Canton 
flannel  and  is  arranged  with  a  solid  back  and  fashioned  in  tails 
at  the  sides  (Fig.  37)  to  allow  of  better  adjustment  to  the  body. 

Its  method  of  applica- 
tion is  taken  up  to- 
gether with  the  abdomi- 
nal protective  dressing 
(page  436). 

The  T  hinder  is 
used  for  operations 
about  the  perineum 
(Fig.  38).  Its  appli- 
cation is  taken  up  with 
operations  in  this  re- 
gion (page  548). 

Cigarette  drains  are 
made  by  rolling  gauze 
in  rubber  tissue.     It  is  essential  that  the  gauze  extend  beyond  the 
rubber  tissue  and  that  the  gauze  be  wet  in  order  to  facilitate  capil- 
larity.    (See  Fig.  154.) 

Ruhher  tuhe  drains  (Fig.  39)  vary  in  size  and  length.  They 
have  a  distinct  and  valuable  field  of  usefulness  in  infected  cases, 
where  they  can  be  introduced  at  the  dependent  portions  of  wounds 


Fig.  38. — T-Bandage  for  Holding  in  Position 
Perineal  Dressings. 


Fig.  39. — Sterile  Rubber  Drainage  Tube  in  Hermetically  Sealed  Glass  Tube. 


and  cavities.  They  will  not,  like  textile  fabric  drainage,  drain  up 
hill.  The  figure  shows  a  desirable  method  of  preservation.  The 
tube  is  boiled  and  inclosed  in  the  glass  tube,  submerged  in  sterile 
water,  and  after  the  tube  is  sealed,  again  boiled.  When  introduced 
into  a  wound  the  tube  is  fenestrated  with  the  view  of  facilitating 
the  entrance  of  infective  material  through  its  entire  length.  The 
mode  of  application  of  this  agent  is  described  under  separate  head 
(page  189). 


REQUISITES  FOR   A  MAJOR   OPERATION  81 

Sterilized  salt  is  placed  in  bottles  in  powder  and  then  sterilized 
again  under  pressure.  The  quantity  in  a  bottle  is  regulated  so 
that  the  entire  contents  of  a  phial  are  used  to  make  the  desired 
percentage  of  solution  when  added  to  two  quarts  of  water.  Chem- 
ically pure  sodium  chlorid  should  be  used.  However,  even  this 
is  apt  to  contain  fine,  insoluble  particles.  To  obviate  this  a  con- 
centrated solution  of  the  salt  is  made,  which  is  carefully  filtered 
through  a  clay  filter  and  placed  in  tubes  similar  to  those  employed 
for  drainage  tubes,  etc.  A  sufficient  amount  of  this  concentrated 
solution  is  placed  in  a  single  tube  to  correspond  to  the  amount  of 
salt  necessary  to  give  the  required  strength  to  two  quarts  of  water. 

When  salt  solution  is  used  for  infusion  or  hypodermoclysis,  the 
necessity  for  an  absolutely  clear  solution  is  manifest.  Hermetically 
sealed  tubes,  as  described,  are  obtainable  in  the  market.  They  are 
exceedingly   convenient   and    are    inexpensive    (Fig.    40).      Just 


r~~ 'omr^s^ 


SALT  SOLOTION 

Fob  INTRA-VCNOUS    INJECTION 


Fig.  40. — Concentrated  Salt  Solution  in  Hermetically  Sealed  Glass  Tube. 

before  use  they  should  be  boiled.  Care  should  be  taken  in  break- 
ing open  the  narrow  end  so  that  no  particles  of  glass  be  allowed 
to  drop  into  the  solution. 

Sterile  towels  should  be  of  soft  cotton.  New  towels  contain 
a  dressing  which  makes  them  stiff.  This  renders  them  less  pli- 
able, and  they  do  not  lie  close  to  the  parts.  When  an  instrument 
or  other  apparatus  is  placed  on  a  new  towel  it  is  liable  to  slip  and 
fall  to  the  floor.  The  towels  should  be  soaked  in  cold  water  over 
night,  washed  in  soap  and  water,  cleansed  by  rinsing  in  several 
changes  of  clean  water,  dried  in  the  air,  folded  in  convenient 
squares,  wrapped  in  muslin,  and  sterilized  under  pressure.  The 
function  of  sterile  towels  is  to  surround  the  operative  field  with 
sterile  surfaces.  The  mode  of  use  is  taken  up  under  operating- 
room  technic  (page  167). 

Self -retaining  catheters  are  described  under  bladder  drainage. 
In  this  connection,  however,  it  is  proper  to  state  that  they  should 
be  boiled,  placed  in  a  glass  tube  similar  to  the  one  used  for  drain- 
age tubes,  and  resterilized  under  pressure.     They  may  be  boiled 


82      STERILIZATION  AND   PREPARATION   OF   INSTRUMENTS 


and  wrapped  in  muslin  and  thus  transported,  or  boiled  imme- 
diately  before   the   operation,   together   with   instruments.      The 

latter  method  is  the  safest. 

Lubricating  agents  are  best 
used  in  collapsible  tubes  (Fig. 
41  A).  The  tubes  are  readily 
sterilized  and  are  filled  with  a 
jelly  made  of  cartilage,  which  is 
soluble  in  water.  The  use  of  lu- 
bricants which  are  soluble  is  de- 
sirable as  compared  with  the 
oleaginous  ones,  permitting  of 
more  thorough  cleansing  of  the 
lubricated  surface. 

When  using  lubricant  in  the 
urethra  the  adjustable  cone  (Fig. 
41 B)  is  a  desirable  refinement, 
permitting  of  the  easy  introduc- 
tion of  the  lubricant  into  the 
urethra  or  other  canal. 

Bath  thermometer  (Fig.  42) 
is    necessary    to    determine    the 
temperature  of  solutions  used  for 
lavage  of  the  wound.      Kot   in- 
frequently    solutions     are     used 
which  are  too  hot,   scalding  the 
tissues  and  interfering  with  re- 
pair of  the  wound.     An  accurate 
determination  of  the  temperature 
of  solutions  employed  will  pre- 
vent this. 
A  rectal  tube  (Fig.  43)  should  be  on  hand  to  permit  of  entero- 
clysis  during  the  operation,  and  for  the  purpose  of  introducing 
various  solutions  into  the  bowel  during  the  after-treatment. 


837 


Fig.  41. — A,  Lubricant  in  collapsible 
metal  tube;  B,  Cones  for  injecting 
lubricant  into  cavities. 


Fig.  42. — Bath  Thermometer  for  Determining  Temperature  of  Solutions. 


REQUISITES  FOR  A  MAJOR  OPERATION 


83 


Fig.  43. — Soft  Rubber  Rectal,  Tube. 


Douche  hags  are  used  for  irrigation,  and  as  a  reservoir  for  solu- 
tions to  be  intro- 
duced into  the 
bowel.  They  have 
been  largely  re- 
placed by  glass 
tanks,  but  the  latter 
are  used  mostly  in 
operating  rooms  in 
hospitals,  the  for- 
mer being  more 
readily  transported 
for  use  during  op- 
erations in  the 
homes  of  patients. 
The  bag  is  so  much 
more  readily  trans- 
ported as  to  have  a 
distinct  field  of  use- 
fulness. A  glass 
terminal  at  the  end 
of  the  rubber  tube 
is  desirable.  The 
bag  should  be 
boiled  before  using. 
The     subject     of 


Fig.  44. — Celiotomy  Sheet. 


84      STERILIZATION   AND   PREPARATION   OF   INSTRUMENTS 

irrigation    is    taken    up    under    operating-room    technic     (page 
151). 

The  celiotomy  sheet  (Fig.  44)  is  a  large  oblong  of  cotton  or 
muslin  with  a  square  opening  near  its  center.  It  should  be  large 
enough  to  hang  over  the  sides  of  the  operating  table,  reaching  al- 
most to  the  floor,  so  that  the  lower  portion  of  the  operator's  gown 
does  not  come  in  contact  with  the  table  (Fig.  121).  Frequently 
during  an  operation  the  surgeon  steps  back  from  the  operating 
table  and  allows  his  hand  to  come  in  contact  with  the  gown  below 
the  waist.  If  this  portion  of  the  gown  has  come  in  contact  with 
the  side  of  the  table,  it  is  contaminated  and  the  hands  are  also 
contaminated.  This  can  be  avoided  by  taking  the  precaution 
mentioned. 


Fig.  45. — Vulvar  Pad  Used  to  Catch  Vaginal  Discharges. 


The  sheet  is  folded  in  a  small  area  and  sterilized  under  pres- 
sure. Its  arrangement  at  the  time  of  operation  is  described  under 
operating-room  technic.  While  the  sheet  shown  is  designed  for 
abdominal  operations  it  may  be  used  in  other  situations.  The 
principle  being  of  isolating  the  part  to  be  operated  upon  with 
sterile  surroundings. 

Rubber  sheets  are  used  to  protect  surrounding  parts  from  mois- 
ture (Fig.  119).  Duck  suits  and  canvas  shoes  are  described  under 
attire  of  the  surgeon  (Figs.  75,  85). 

Vulvar  pads  (Fig.  45)  are  placed  against  the  vaginal  outlet 
following  operations  in  this  region,  and  when  vaginal  drainage  has 
been  made  following  celiotomy.  The  pads  are  composed  of  gauze 
with  several  layers  of  absorbent  cotton  held  between  its  layers. 


CHAPTEK    IV 
SUTURE   AND   LIGATURE   MATERIAL 

General  considerations  of  absorbable  and  non-absorbable  material. 

Absorbable  ligature  material:  Catgut:  Plain  catgut;  sterilization  of  catgut, 
by  biniodid  of  mercury,  by  heating  in  fatty  liquid:  Chromic  catgut;  steri- 
lization of  catgut  with  cumol:  Iodin  catgut — Kangaroo  tendon. 

Non-absorbable  ligature  material:  Silk-worm  gut — Silk — Pagensteeher  thread 
— Horse  hair — Silver  and  gold  wire. 

GENERAL   CONSIDERATIONS    OF    ABSORBABLE   AND   NON- 
ABSORBABLE  LIGATURE   MATERIAL 

The  aim  of  suturing  wounds  is  to  hold  tissue  in  apposition, 
until  repair  by  cell  genesis  takes  place.  Sutures  are  not  concerned 
directly  in  repair,  they  place  the  tissues  in  such  relationship  to 
each  other  as  to  make  repair  rapid  and  easy,  but  of  themselves 
will  not  hold  tissues  together  as  a  nail  holds  two  boards  or  a  bolt 
two  pieces  of  metal  in  apposition.  This  consideration  should  be 
a  plea  against  the  strangulation  of  tissue,  the  outcome  of  tightly 
drawn  stitches  so  frequently  seen.  The  ideal  suture  is  one  which 
is  sterile,  non-irritating,  is  absorbed  at  the  expiration  of  the  time 
required  for  healing,  and  is  of  sufficient  tensile  strength  to  per- 
mit of  the  necessary  manipulations  without  breaking  asunder. 

As  a  general  proposition  suture  material  which  is  absorbed 
should  be  employed  in  deep  suturing.  Material  which  it  is  neces- 
sary to  ultimately  remove  may  be  employed  in  superficial  repair. 

Dividing  suture  material  into  two  classes — the  one  absorb- 
able, the  other  non-absorbable — we  may  say  that  the  latter  is  less 
apt  to  be  a  carrier  of  infection,  on  the  simple  and  easily  under- 
stood ground,  that  the  quality  which  renders  them  resistant  to  the 
action  of  the  circulating  fluids  in  the  body,  also  makes  them  un- 
influenced by  the  manipulations  necessary  to  complete  steriliza- 
tion. 

In  addition  to  this,  the  modification  of  consistence  which  an 

85 


86  SUTURE  AND   LIGATURE   MATERIAL 

absorbable  suture  material  undergoes  in  absorption,  creates,  at 
a  certain  time  of  the  process,  a  condition  favorable  to  infection. 
This  obtains  more  readily  in  sutures  a  part  of  which  lie  on  the 
skin,  and  would  argue  for  the  employment  of  non-absorbable  su- 
ture material  in  this  situation,  a  notion  borne  out  by  the  facts  as 
observed  in  practice. 

The  complications  arising  in  the  after-treatment  of  operative 
cases  are  commonly  enough  the  outcome  of  disturbances  caused 
by  sutures  and  ligatures.  These  are  taken  up  under  a  separate 
head  (page  211). 

The  method  of  preparing  suture  material  bears  an  important 
relationship  to  postoperative  occurrences,  and  the  technic  of  steril- 
ization is  extensively  gone  into  in  this  connection  for  this  reason. 

Absorbable  suture  and  ligature  material :  Catgut,  kangaroo 
tendon. 

Non-absorbable  suture  and  ligature  material :  Silk,  silk-worin 
gut,  Pagenstecher  thread,  Silver  and  gold  wire. 

ABSORBABLE    LIGATURE   MATERIAL 

CATGUT 

Catgut,  so-called,  would  be  an  ideal  suture  material  were  it 
not  for  the  fact  that  it  is  difficult  to  sterilize.  It  is  not,  as  the 
name  implies,  made  from  the  intestine  of  the  cat,  but  is  taken 
from  the  small  intestine  of  the  sheep.  It  is  obtainable  in  the 
market,  dry  and  of  varying  thickness.  The  diameter  of  the 
product  is  designated  by  number,  i.e.,  00,  0,  1,  2,  and  3.  This 
classification  is  somewhat  arbitrary,  and  the  diameter  of  the 
product  is  quite  variable.  However,  but  little  acquaintance  in 
a  practical  way  renders  it  sufficiently  accurate. 

It  is  easy  to  see  that  the  material  composing  the  catgut  is  the 
natural  habitat  of  bacteria.  The  bacteria  exist  throughout  the 
entire  thickness  of  the  gut,  and  any  method  of  sterilization  to  be 
effective  involves  the  problem  of  penetration  of  its  entire  thick- 
ness by  a  process  which  does  not  destroy  its  tensile  strength.  The 
writer  wishes  to  state  that  for  general  purposes,  with  perhaps 
the  exception  of  large  hospitals,  suture  and  ligature  material  is 
best  and  most  safely  handled  by  commercial  houses  who  make  a 
specialty  of  preparing  and  sterilizing  them. 


ABSORBABLE   LIGATURE  MATERIAL 


87 


The  problem  of  sterilization  of  catgut  is  so  complicated  that, 
unless  special  apparatus  and  experience  is  employed,  unfavor- 
able and,  indeed,  at  times  fatal  outcome  obtains. 

Two  kinds  of  raw  catgut  are  generally  employed,  the  smooth 


and  the  rough. 


Smooth  catgut  is  of  the  best  quality  of  imported  (Germany) 
banjo    and    violin    strings,    put    up    in    boxes    containing    thirty 


strings  of  each  of  the  sizes. 


Designation. 


Average  Length. 


Banjo  1   (thinnest) 67^  in. 

Banjo  2 67-|  in. 

Violin  E 671  in. 

Violin  A 444,  in. 

Violin  D  (heaviest) 44£  in. 


Average 

Breaking 

Point. 

5  lbs. 

8  lbs. 
18  lbs. 
24  lbs. 
32  lbs. 


The  first  three  sizes  are  those  mostly  used  in  surgery.  Each 
string  is  coiled  or  arranged  in  a  manner  shown  in  Fig.  46, 
and  tied  with  a  strand  of  silk. 
Colored  silk  colors  the  solutions 
used. 

Rouffh  catgut  is  the  kind  which 

It 


clockmakers  and   jewelers  use. 


comes  in  strings  of  five  meters  in 
length,  of  various  sizes ;  00,  0,  1, 
2,  and  3  are  most  commonly  used. 
(Bryant.) 

A  large  number  of  methods  of 
preparing  catgut  for  ligatures  and 
sutures  have  been  employed.  None 
of  these  are  effective  unless  care- 
fully employed  and  accurately  exe- 
cuted. Of  all  the  methods  the  so- 
called  cumol  and  dry  sterilization 
is  the  most  certain,  and  is  univer- 
sally applicable. 

Three  kinds  of  prepared  catgut 
will  be  described :  the  plain,  the 
chromicized,  and  the  iodized.     The 


Fig.    46. — Catgut     Looped     and 
Ready  for  Sterilization. 


88  SUTURE   AND   LIGATURE   MATERIAL 

former  two  necessitate  the  removal  of  the  fats  from  the  raw  ma- 
terial, the  latter  does  not. 

Plain  catgut  is  more  readily  absorbed  than  the  chromic,  is 
more  pliable,  and  consequently  ties  a  closer  knot  than  chromic, 
though  the  latter  is  strongen,  remains  in  situ  longer,  and  is  more 
readily  handled.  The  exact  place  which  iodin  catgut  occupies 
is  difficult  to  state.  In  its  preparation  it  frequently  undergoes  a 
change  which  lessens  its  tensile  strength.  This  is  a  serious  ob- 
jection. It  is  most  useful  in  hospital  practice,  where  it  is  used 
soon  after  preparation.  The  simplicity  of  preparation  is  a  strong 
factor  as  regards  its  field  of  usefulness.  On  the  whole,  the  plain 
and  chromic  gut  fill  all  wants,  i.e.,  if  properly  prepared. 

Removal  of  Fats  from  Catgut. — A  number  of  coils  of  gut  3 
feet  in  length  (Fig.  46)  are  placed  in  an  Erlenmeyer  flask  and 
submerged  in  ether.  Most  manufacturers  who  prepare  catgut  for 
surgical  use  allow  the  material  to  lie  in  ether  for  a  month,  chang- 
ing the  ether  bath  at  intervals,  with  the  view  of  removing  the  fats 
held  in  solution,  and  substituting  fresh  ether  which  will  permit 
of  additional  chemical  action. 

If  sufficient  facilities  for  this  be  not  available,  the  flask  con- 
taining the  submerged  gut  is  exposed  to  steam  and  the  fats  boiled 
out  with  ether.  The  top  of  the  flask  is  connected  with  a  con- 
denser to  save  the  vaporized  ether.  Care  should  be  taken  not  to 
allow  the  open  flame  to  come  in  contact  with  the  ether  vapor. 
The  ether  should  be  distilled  before  using  a  second  time.  The 
ether  is  poured  off  while  hot,  and  the  boiling  should  continue  for 
one  hour.  Some  fat  will  remain  in  the  gut  after  the  ether  ex- 
traction is  completed.  This  may  be  removed  by  boiling  the  gut  in 
alcohol,  preferably  absolute  alcohol,  though  the  commercial  95 
per  cent,  will  serve  the  purpose.  If  the  percentage  of  water  in 
the  alcohol  is  greater  than  5  per  cent.,  the  moisture  will  cause 
the  gut  to  swell  up,  tangle,  and  lose  its  tensile  strength. 

Sterilization  of  Catgut. — The  destruction  of  bacteria  in  gut 
by  chemical  action,  such  as  immersion  in  a  solution  of  biniodid 
of  mercury  in  chloroform,  bichlorid  of  mercury  in  alcohol,  etc., 
has  been  employed  for  many  years  and  has  given  results  which 
have  seemed  to  be  desirable.  However,  latterly  the  subject  of 
catgut  sterilization  has  been  made  the  object  of  scientific  investi- 
gation, which  seems  to  show  that  chemical  treatment  of  catgut 


ABSORBABLE   LIGATURE   MATERIAL  89 

does  not  achieve  sterility.  This  has  been  shown  by  making  cul- 
tures from  raw  gut,  treating  them  with  antiseptic  solutions,  such 
as  are  mentioned  above,  precipitating  the  antiseptic  with  the 
proper  chemical  agent,  making  cultures  again,  and  noting  the 
development  of  growths  of  pathogenic  bacteria.  Again,  in  sev- 
eral instances  tetanus  has  developed  as  the  outcome  of  using  gut 
prepared  by  immersion  in  antiseptics.  However,  a  number  of 
surgeons  regard  the  sterilization  of  catgut  by  the  chloroform- 
biniodid  method  as  efficient,  and  it  is  described  here  for  that  rea- 
son, though  employment  of  the  method  is  not  advised  by  the  writer. 

Sterilization  of  catgut  by  a  solution  of  biniodid  of  mercury 
is  a  simple  method.  After  the  gut  has  been  subjected  to  ether  ex- 
traction of  the  fats,  it  is  at  once  transferred  to  a  saturated  solu- 
tion of  biniodid  of  mercury  in  chloroform,  in  which  it  is  copi- 
ously submerged.  The  chloroform  saturates  at  1  in  1,000  of 
biniodid  of  mercury.  The  gut  is  stored,  thus  submerged,  in  a 
glass-stoppered  jar  (Fig.  48),  and  is  ready  for  use.  Sufficient 
quantity  for  immediate  use  is  removed  by  means  of  a  sterile 
dressing  forceps,  and  the  stopper  is  replaced.  The  glass  con- 
tainer should  not  be  left  open  during  an  operation,  as  an  error 
is  very  likely  to  occur,  the  assistant  being  liable  to  use  a  fer- 
tilized instrument  for  the  purpose. 

It  is  true  that  a  combination  of  chemical  agents  and  heat  will 
achieve  the  desired  result,  yet  it  is  to  be  borne  in  mind  that  heat 
is  the  most  reliable  bactericidal  agent. 

The  treatment  of  catgut  with  chemical  agents  should  be  des- 
tined to  influence  its  pliability  and  tensile  strength  and  to  offset, 
as  far  as  possible,  the  destructive  effect  of  heat.  It  is  just  as  fair 
to  assume  that  a  chemical  agent  of  sufficient  strength  to  destroy 
bacteria  may  also  probably  destroy  the  characteristics  of  the  gut 
which  make  it  of  use.  This  is  shown,  in  a  way,  in  iodin  catgut, 
which  is  sterile  after  being  immersed  in  iodin  solution,  yet  fre- 
quently is  of  no  use  at  the  time  of  the  operation  because  of  the 
destructive  effect  of  the  iodin  when  submerged  for  a  consider- 
able period  of  time. 

Heating  of  Catgut  in  Fatty  Liquid. — After  extraction  of  fat 
and  immersion  in  a  solution  of  chloroform  and  biniodid,  as 
stated,  the  gut  is  wound  on  bobbins  (Fig.  47).  Each  bobbin 
holds  several  strands  of  three  feet  each.     The  bobbins,  which  are 


90 


SUTURE   AND    LIGATURE   MATERIAL 


sterile,  are  put  into  a  vessel,  submerged  in  albolene,  and  heated 
over  a  petrolatum  bath.  The  temperature  is  run  up  to  275°  F., 
where  it  is  maintained  for  fifteen  minutes.  The  temperature  is 
then  allowed  to  fall  and  the  gut  on  the  bobbins  returned  to  the 
chloroform  and  biniodid  of  mercury  solution.  This  method  is 
a  good  one,  but  does  not  permit  of  the  raising  of  the  temperature 

sufficiently  high  to  enable  one 
to  be  certain  that  all  bacteria 
have  been  destroyed. 

Chromicized  Gut. — The  fats 
are  removed,  as  described  above, 
and  the  gut  is  then  wound  on 
bobbins  (Fig.  47)  or  arranged 
in  coils  (Fig.  46)  and  sub- 
merged in  the  following  solu- 
tion: 

Potassium  bichromate .  22^  grs. 
Distilled  water 15     oz. 

dissolve  and  add 

Glycerin 2^  drachms. 

Carbolic  acid 2^  drachms. 

The  gut  is  allowed  to  re- 
main in  this  solution  during 
thirty  hours.  It  is  then  re- 
moved and  tightly  stretched  on 
a  notched  board  and  allowed  to 
dry  in  the  air  or  in  an  oven  at 
a  temperature  of  113°  F. 

When  the  gut  is  dry,  it  is 
coiled  again,  and  after  being  placed  in  a  glass  jar  (Fig.  48), 
sterilized  in  alcohol  vapor  under  pressure.  The  various  sizes  of 
catgut  should  be  placed  in  separate  jars,  each  labeled  (Fig.  49) 
with  the  view  of  obviating  confusion  when  the  contents  are  to  be 
used.  The  illustration  shows  a  method  of  arrangement  which  is 
satisfactory  in  this  connection. 

The  chemical  treatment  is  destined  to  make  the  gut  strong  and 


Fig.  47.- 


-Catgxjt   Wound   on    Bobbin, 
Ready  for  Use. 


ABSORBABLE   LIGATURE   MATERIAL 


91 


hard,  so  as  to  be  maintained  in  the  tissues  for  varying  periods 
without  absorption.  It  does  not  sterilize  the  gut.  Indeed,  the 
hardness  of  the  product  makes  the 
gut  less  readily  sterilized.  The  ex- 
posure to  alcohol  vapor  under  press- 
ure is  expected  to  do  this.  The 
writer  regards  this  as  a  quite  uni- 
versally useful  method,  but  would 
replace  the  alcohol  vapor  steriliza- 
tion with  exposure  to  dry  heat  at  a 
temperature  of  250°  F  (see  cumol 
method,  page  92).  Chromicized 
catgut  is  stiff  and  hard.  To  over- 
come this  the  gut,  after  being  chro- 
micized, has  been  subjected  to  the 
albolene  boiling  as  described  above. 
The  same  objection  to  the  employ- 
ment of  this  method  applies  in  this  connection. 

Sterilization  of  Catgut  with  Cumol. — The  method  here  de- 
scribed is  regarded  by  the  writer  as  the  safest,  and  if  properly  car- 
ried out,  gives  uniformly  satisfactory  results.     It  applies  to  both 


Fig.  48.  —  Catgut  Coils  Sub- 
merged in  a  Solution  of 
Biniodid  of  Mercury  in 
Chloroform. 


■BmBH 

HI         ji 

'U?J?_ 

I       1  „ 

mm  ; 

IdP 

^)k^3^    4 

Fig.  49. — Convenient  Arrangement  of  Jars  Containing  Catgut  for 
Immediate  Use. 


plain  and  chromic  gut,  for,  of  course,  the  latter  is  not  sterilized 
by  the  process  which  chromicizes  it. 

The  apparatus  used  for  drying  and  cumolizing  catgut  is  de- 
scribed as  follows  (Fig.  50)  :  The  sterilizer  is  made  throughout  of 
brass  and  bronze,  nickel-plated.  The  interior,  or  cumol-retaining 
cylinder,  is  6  inches  in  diameter  and  8  inches  deep.    The  outer  cyl- 


92 


SUTURE   AND   LIGATURE  MATERIAL 


inder  is  8  inches  in  diameter  and  8y2  inches  deep,  providing  for  an 
intervening  space  of  1  inch  all  around  between  the  two,  and  1^ 
inches  from  the  bottom  of  the  outer  cylinder.  This  space  between 
the  two  cylinders  is  compactly  filled  with  white  sand.     The  top  of 

the  sterilizer  articulates 
closely  with  the  cast 
bronze  "  faced  "  ring  se- 
cured to  the  upper  end 
of  the  retaining  cylinder, 
forming  a  steam-tight 
joint. 

The  apparatus  is  sup- 
ported on  four  legs, 
which  rest  in  a  metal 
tray,  as  shown  in  the 
illustration.  The  heat  is 
furnished  by  means  of  a 
Bunsen  burner,  though 
an  alcohol  flame  or  other 
source  of  heat  may  be 
used  for  the  purpose. 
The  heat  is  directed 
against  the  bottom  of  the 
outer  cylinder,  heating 
the  quartz  bath  uni- 
formly, and,  in  turn, 
transmitting  uniform 
heat  to  the  cumol.  The 
cumol  sterilizer  is  pro- 
vided with  a  draw-off 
valve,  thermometer,  and 
a  burner  consistent  with 
the  fuel  at  disposal. 
The  gut  is  cleansed  and  the  fats  extracted  in  the  way  already 
described,  cut  into  lengths  of  three  feet  and  coiled  (Fig.  47),  then 
placed  in  the  interior  cylinder  of  the  cumolizer  (Fig.  50),  and 
the  apparatus  closed.  The  temperature  is  raised  to  80°  C.  and 
maintained  there  for  two  hours,  at  the  end  of  which  time  all  mois- 
ture is  driven  from  the  gut,  thus  preventing  it  from  becoming 


Fig. 


50. — Apparatus     for     Sterilization 
Catgut  by  the  Cumol  Method. 


ABSORBABLE   LIGATURE   MATERIAL  93 

brittle  during  the  subsequent  steps  of  its  preparation,  the  result 
of  conversion  of  the  animal  tissue  into  a  glue-like  substance. 

The  gut  is  then  submerged  in  cumol,  and  the  temperature  raised 
to  155°  C.  and  maintained  for  one  hour.  The  cumol  is  then  drawn 
off  through  a  tube  at  least  24  inches  in  length  attached  to  the  lower 
spout  (Fig.  50),  and  the  rest  of  the  cumol  driven  off  by  main- 
taining a  temperature  of  100°  C.  for  about  two  hours. 

The  gut  is  then  removed  and  stored  in  either  glass  tubes  or 
jars  (Fig.  49).  The  gut  in  the  jars  is  covered  with  a  solution 
of  mercuric  biniodid,  1  in  1,000.  The  latter  precaution  is  taken 
to  prevent  contamination  of  the  gut  when  removing  a  portion  of 
the  contents  of  the  jar. 

The  objection  to  storing  sterilized  catgut  in  jars,  for  fear  of 
subsequent  contamination,  has  been  overcome  by  placing  the  pre- 


Fig.  51. — Sterile  Catgut  in  Hermetically  Sealed  Glass  Tubes. 
broken  at  file  scratch. 


Tube 


pared  suture  and  ligature  material  in  hermetically  sealed  glass 
tubes.  The  gut  is  coiled  or  wound  on  a  metal  bobbin,  placed  in  the 
glass  tube,  and  after  being  sterilized  in  cumol,  as  described,  at  a 
temperature  of  300°  F.  for  two  hours,  the  tube  is  sealed  and  re- 
sterilized  for  one  hour  at  18  lbs.,  in  a  steam  pressure  sterilizer 
(Fig.  21).     This  is  an  ideal  way  of  handling  catgut. 

The  glass  tube  is  scratched  with  a  file  mark  near  its  middle, 
and  when  the  tube  is  opened  it  is  readily  broken  at  this  point  (Fig. 
51).  A  sterile  towel  should  be  used  for  the  purpose  to  prevent  in- 
jury from  the  broken  glass  to  the  surgeon's  fingers.  In  this  way 
contamination  of  the  material  during  transportation  is  made  im- 
possible, and  it  is  only  necessary  to  sterilize  the  outside  of  the  tube 
at  the  time  of  the  operation. 


94  SUTURE   AND    LIGATURE   MATERIAL 

The  latter  object  is  attained  by  sterilization  by  boiling  simul- 
taneously with  the  instruments,  or  by  submerging  the  sealed  tube 
in  a  solution  of  bichlorid  of  mercury  for  an  hour  before  opening 
it,  in  the  manner  stated. 

When  the  gut  is  in  the  glass  tube,  the  solution  in  which  it  is 
submerged  magnifies  its  diameter.  To  obviate  error  with  respect 
to  the  size  when  removed  from  its  sterile  container,  each  tube 
should  contain  a  small  label  registering  its  size,  thus  preventing 
annoying  delay  and,  indeed,  unnecessary  waste  of  material.  A 
label  affixed  to  the  surface  of  the  tube  would  not  fill  the  purpose, 
for  the  obvious  reason  that  it  would  come  off  during  either  the 
heat  or  chemical  sterilization  of  the  tube. 

As  a  rule,  Number  2  catgut  is  the  most  widely  employed. 
Number  2  plain  gut  is  generally  employed  for  ligature  of  bleeding 
vessels  divided  during  operation.  Plain  gut,  as  a  rule,  should  be 
employed  for  ligature  of  pedicles  and  the  omentum.  The  chromic 
gut  is  too  hard,  does  not  allow  of  a  tight  knot,  and  is  liable  to  slip. 
Number  3  is  as  large  as  is  ever  necessary  for  the  purpose  of  deli- 
gating  tissues. 

On  the  whole,  it  may  be  said  that  the  smaller  the  gut  the  less 
is  the  liability  of  infection,  as  the  finer  kind  is,  as  can  easily  be 
seen,  more  readily  sterilized  than  the  heavier.  In  a  given  case  it 
would  be  better  to  use  several  strands  of  finer  gut  than  one  heavy 
strand,  for  the  same  reason.  The  ISTumber  1  may  be  used  for 
tying  smaller  vessels  and  the  0  and  00  for  apposition  of  wounds 
where  cosmetic  effect  is  a  consideration,  such  as  in  the  face,  neck, 
and  hands. 

Chromic  gut  is  employed  where  apposition  is  to  be  maintained 
for  a  considerable  period  of  time.  Muscle  fibers  which  have  been 
divided  should  be  held  in  place  with  chromic  gut,  though  it  will 
rarely  be  necessary  to  use  heavier  than  Number  3.  Catgut  in  the 
skin  is  unreliable,  though  chromic  gut  gives  better  results  than  the 
plain  in  this  situation.  The  writer  has  abandoned  the  use  of  cat- 
gut in  the  skin,  and  uses  silk-worm  gut  where  cosmetic  effect  need 
not  be  considered,  and  horsehair  on  the  face.  The  question  of 
kind  of  suture  to  be  used  in  a  given  portion  of  the  body  will  bo 
taken  up  under  the  head  of  suturing  of  wounds  (page  211). 

In  this  connection,  mention  may  be  made  of  the  simultaneous 
sterilization  of  a  suture  and  needle  for  emergencies.     The  suture 


ABSORBABLE   LIGATURE  MATERIAL  95 

material,  as  has  been  seen,  is  readily  rendered  sterile,  but  when 
an  emergency  arises,  a  sterile  needle  is  not  always  available.  To 
meet  this  contingency,  a  suture  is  threaded  on  a  needle  and  placed 
in  a  glass  tube,  which  is  then  sterilized  in  the  manner  stated  in 
connection  with  sterilization  of  catgut    (page   94).     It   is  only 


Fig.  52. — Emergency  Sutures  with  Needle  (^  Curved)  in  Hermetically 

Sealed  Tubes. 

necessary  to  break  the  incasing  glass  tube  to  have  the  little  ap- 
pliance at  the  disposition  of  the  surgeon. 

The  method  is,  of  course,  available  for  suture  material  other 
than  catgut,  in  which  instances  the  sterilization  and  preservation 
is  carried  out  in  accord  with  the  means  employed  for  sterilization 
of  the  particular  kind  of  suture  material  used. 

Iodin  Catgut. — Theoretically,  iodin  catgut  is  sterilized  by  the 
iodin  it  is  soaked  in,  and  as  it  is  absorbed,  destroys  whatever  bac- 
teria may  come  in  contact  with  it  from  extrinsic  causes  during 
absorption.  Unfortunately,  the  chemical  action  of  the  iodin  de- 
stroys the  tensile  strength  of  the  gut  at  the  expiration  of  a  certain 
period  of  time.  However,  if  the  gut  is  used  in  large  quantities, 
as  obtains  in  hospital  practice,  the  iodin  sterilization  and  preser- 
vation is  an  exceedingly  useful  method.  The  gut,  when  treated  in 
this  way,  is  pliable  and  easily  handled,  and,  indeed,  if  the  objec- 
tion stated  could  be  removed  with  certainty,  would  be  an  ideal 
ligature  and  suture  material.  The  raw  gut  is  used  for  the  pur- 
pose ;  neither  the  ether  nor  alcohol  bath  is  necessary. 

The  gut  is  rolled  on  glass  spools  (Fig.  47)  (when  fashioned 
into  coils  it  is  believed  to  rot  more  rapidly)  and  immersed  in  the 
f ollowing  solution : 


96  SUTURE  AND   LIGATURE  MATERIAL 

Iodin 1  per  cent. 

Potassium  iodid 1  per  cent. 

Sterile    water 98  per  cent. 

The  gut  is  allowed  to  remain  in  the  solution  for  eight  days,  when 
it  is  ready  for  use.  As  a  rule  it  is  preserved  in  a  glass  jar  (Fig. 
48),  though  it  may  be  put  in  tubes  and  covered  with  the  solution 
mentioned.     (Fig.  51.) 

If  iodin  catgut  is  preserved  in  a  sealed  glass  tube,  the  latter 
must  be  sterilized  in  cold  antiseptic  solution  just  before  using.  If 
the  tubes  are  boiled  with  the  instruments,  the  catgut  is  disinte- 
grated, becomes  friable,  and  is  useless.  The  theory  of  impregnat- 
ing catgut  with  iodin  is  that,  as  the  gut  is  absorbed,  the  iodin 
chemically  combats  accidental  infection.  Theoretically,  this  looks 
rational,  yet  experience  has  not  quite  sustained  this  view. 

KANGAROO   TENDON 

Kangaroo  tendon,  as  its  name  implies,  is  made  from  the  tendon 
of  the  kangaroo.  It  will  not  stand  heat  and  must  be  sterilized  by 
immersion  in  antiseptic  fluids.  It  is  not,  however,  the  natural 
habitat  of  bacteria,  as  is  catgut,  and  is  rendered  sterile  without 
heat.  Its  preparation  is  simple.  The  tendon  is  extracted  with 
ether,  which  removes  the  fats,  immersed  in  a  mixture  of  albolene 


Fig.  53. — Kangaroo  Tendon  Sutures  in  Hermetically  Sealed  Glass  Tube. 

and  camphor  3  per  cent.,  containing  mercuric  bichlorid  1  in 
4,000,  in  which  it  is  soaked  for  a  week.  It  is  then  put  in  glass 
tubes  (Fig.  53),  submerged  in  fresh  bichlorid  and  albolene  mix- 
ture, the  tube  sealed  and  sterilized  in  cold  bichlorid  of  mercury 
solution  just  before  use.  It  must  be  borne  in  mind  that  it  must 
not  be  boiled  with  the  instruments. 

Kangaroo  tendon  is  used  where  prolonged  immobilization  of 
traumatized  parts  is  indicated,  such  as  holding  the  fragments  of 
fractured  bones  in  place,  for  suturing  fractured  patella,  and  the 


NON-ABSORBABLE    LIGATURE    MATERIAL 


97 


like.  It  may  be  obtained  in  the  market  in  so-called  large,  medium, 
and  small  sizes.  The  large  size  is  used  to  hold  fragments  of  bones 
in  apposition  and  the  medium  and  small  for  the  same  purpose  as 
regards  ruptured  tendons. 

It  is  slowly  absorbed,  and  at  times,  in  cases  in  which  the  heavier 
grade  has  been  used,  requires  removal  because  of  its  persistence 
in  the  tissues.  It  is  used  (small  size)  in  herniotomy  for  radical 
cure. 

On  the  whole,  its  field  of  actual  usefulness  is  small,  the  proba- 
bilities being  that  it  possesses  no  advantage  over  properly  pre- 
pared chromic  gut  in  its  application  to  soft  parts  and  none  beyond 
silver  wire  with  respect  to 
maintaining  apposition  of 
bones. 


NON-ABSORBABLE   LIG- 
ATURE  MATERIAL 

SILK-WORM  GUT 

Silk-worm  gut  is  the 
fiber  drawn  from  the  body 
of  the  silk  worm  killed  just 
as  it  is  ready  to  spin  its  co- 
coon. It  is  smoother  than 
silk  and  is  more  easily 
cleansed.  It  is  obtainable 
in  the  market  in  hanks 
about  fourteen  inches  in 
length  (Fig.  54).  It  can 
be  boiled  without  damage  and  is  sterilized  by  boiling.  The  sim- 
plicity of  the  measure  for  rendering  it  sterile  recommends  its  use 
when  indicated. 

It  is  used  most  frequently  in  the  skin,  and  being  of  small 
diameter,  it  leaves  only  small  stitch-hole  scars.  It  is  not  absorbed 
and  must  be  removed  when  healing  has  taken  place.  Its  whitish 
color  renders  it  difficult  to  see  after  it  has  been  in  situ  for  a  time, 
more  especially  if  the  stitches  are  buried  in  the  slight  crust  which 
covers  the  line  of  incision.    This  has  been  overcome  by  dyeing  the 


Fig.  54. — Silk-worm  Gut  in  Hank. 


98 


SUTURE  AND   LIGATURE  MATERIAL 


silk-worm  gut  black.  It  is  thus  more  readily  found,  and  removed 
with  less  disturbance  to  the  patient,  a  desirable,  if  not  essential, 
refinement  in  surgical  technic.  For  immediate  use  the  gut  is 
stored,  after  boiling,  in  glass  tubes,  submerged  in  a  solution  of 
bichlorid  of  mercury,  1  in  2,000,  in  70  per  cent,  alcohol  (Fig.  55). 
About  six  sutures  are  placed  in  a  single  tube. 

This  suture  is  a  desirable  one  for  office  use,  especially  in  manu- 


Fig.  55. — Iron-dyed  Silk-worm  Gut  in  Glass  Tube. 

facturing  towns  where  the  surgeon  is  called  upon  to  make  repair 
of  trauma  in  his  office  at  short  notice. 

The  finer  grades  are  intended  to  take  the  place  of  horsehair. 
However,  very  fine  silk-worm  gut  is  not  as  easily  handled  as  the 
stiffer  horsehair,  which  still  holds  its  place  as  an  exceedingly  use- 
ful suture  material,  where  accurate  coaptation  of  wounds  is 
necessary. 

It  is  the  experience  of  the  writer  that  stitch  abscess  occurs  less 
frequently  when  silk-worm  gut  is  used  in  the  skin  than  with  any 
other  suture  material.  Its  field  of  usefulness  is  only  that  of  a 
suture ;  it  is  of  no  value  as  a  ligature  for  obvious  reasons,  the  most 
determining  of  which  is  the  fact  that  it  cannot,  because  of  its 
stiffness,  be  tied  in  a  close  knot. 


SILK 

Silk  for  suture  and  ligature  is  obtainable  in  the  market  in  two 
forms,  twisted  and  braided.  The  twisted  is  used  for  finer  sutures 
and  the  braided  for  retention  suture  and  ligature  of  large  pedicles. 
Its  advantages  are  that  it  is  readily  sterilized,  easily  applied,  and 
remains  firmly  tied.  It  is,  however,  readily  infected  and  is  not 
absorbed.  Silk  is  sterilized  by  boiling  for  ten  minutes  in  a  1  per 
cent,  aqueous  solution  of  sodium  carbonate. 


NON-ABSORBABLE    LIGATURE    MATERIAL 


99 


Fig.  56. —  Surgeons  Silk  Wound 
on  Cardboard. 


Haegler  seems  to  have  shown  that  sterilization  of  silk  by  heat 
is  not  sufficient,  claiming  that  the  drawing  of  the  material  through 
the  hands  and  the  manipulations  necessary  to  threading  it  on 
needles  cause  reinfection.  Of  course  this  is  true  of  all  suture  and 
ligature  material.  It  would,  per- 
haps, be  fairer  to  say  that  silk,  be- 
cause of  its  nature,  is  more  readily 
infected  during  manipulation  than  the 
smoother  suture  materials,  a  concep- 
tion which  seems  rational.  However, 
if  the  silk  is  boiled  immediately  be- 
fore an  operation,  it  will  be  sterile, 
and,  indeed,  it  is  suggested  that  silk 
be  kept  wound  on  the  cardboard  as  it 
comes  from  the  manufacturer  (Fig. 
56)  and  boiled  with  the  instruments, 
rather  than  sterilized  in  soda  solution 
and  then  preserved,  wound  on  bobbins, 
in  antiseptic  solution.  However,  if 
the  surgeon  insist  that  sterile  silk  be 
constantly  available,  the  indications  may  be  met,  as  done  by 
Kocher. 

The  silk  is  treated  for  twelve  hours  with  ether  and  alcohol  to 
extract  the  fats.  It  is  then  boiled  for  ten  min- 
utes in  a  1-1,000  solution  of  bichlorid  of  mer- 
cury, and  rolled  on  sterile  glass  spools  (Fig. 
57),  after  the  hands  have  been  cleansed  and  in- 
cased in  rubber  gloves.  The  spools  of  silk  are 
then  again  boiled  in  a  1-1,000  bichlorid  of  mer- 
cury solution.  Various  sizes  of  silk  may  be 
arranged  on  spools  in  a  glass  jar  arranged  as 
shown  in  Fig.  58,  a  very  convenient  method  of 
handling  the  material.  The  albumin  of  the 
silk  forms  a  chemical  union  with  the  mercury, 
which  is  slowly  extracted  by  the  fluids  of  the 
circulation  in  the  body.  The  mercury  grad- 
ually disappears  from  the  suture  in  from  five  to  ten  days.  Haegler 
does  not  believe  that  the  small  amount  of  mercury  present  in  the 

suture  destroys  bacteria,  but  checks  their  growth. 
9 


Fig.   57. — Silk   on 
Spools.   (Bryant.) 


100 


SUTURE   AND   LIGATURE   MATERIAL 


Silk,  on  general  principle,  should  not  be  used  for  ligatures  or 
buried  sutures.  It  is  being  less  and  less  used  as  the  art  of  pre- 
paring absorbable  suture  material  becomes  perfected. 

It  has  a  distinct  field  of  usefulness  in  intestinal  surgery.  For 
this  purpose,  a  very  fine  grade  of  silk  is  used, 
and  should  be  dyed  black  so  as  to  permit  of 
closer  scrutiny  when  being  placed  in  situ.  The 
operative  field  is  apt  to  be  bloody,  and  white 
silk  soon  takes  on  the  color  of  the  medium  in 
which  it  is  being  used.  If  a  reliable  absorbable 
suture  material  of  sufficient  tensile  strength  and 
as  great  pliability  as  silk  were  devised,  an  ideal 
'' '^   N ,,, , JJIliNll        intestinal  suture  would  be  achieved. 


Silk    is    being;    used    for 


deligating 


large 


pedicles  and  the  broad  ligament  in  salpingec- 
tomy. It  should  never  be  used  for  the  latter 
purpose,  and  but  rarely  for  the  former.  Silk 
sutures  or  ligatures,  while  they,  more  especially 
in  regard  to  the  latter,  give  the  surgeon  a  feel- 
ing of  security  as  to  the  permanency  of  the  knot, 
give  rise  to  adhesions,  because  of  the  prolonged 
irritation  common  to  all  foreign  bodies  in  the 
tissues,  and  not  infrequently  they  are  the  causa- 
tive factor  in  intestinal  obstruction  following 
celiotomy.  In  intestinal  suturing  the  area  of 
exposed  suture  is  so  small  as  to  be  perhaps  a 
minor  factor  in  this  connection,  yet  non-absorbable  suture  ma- 
terial in  closed  cavities  is  never  as  desirable  an  agent  for  repair 
as  the  kind  which  is  taken  up  by  the  circulating  fluid. 

For  operations  in  private  practice  silk  may  be  preserved  in 
glass  tubes.  The  braided  (Fig.  59)  and  the  twisted  (Fig.  60)  are 
both  put  up  in  this  way. 


Fig.  58.  -Wide- 
mouthed  Bottle 
for  Ligatures. 
(Bryant.) 


PAGENSTECHER  THREAD 

Pagenstecher  thread  is  a  linen  thread  which  has  been  dipped 
in  a  solution  of  celluloid.  It  is  readily  obtained  in  the  market  in 
skeins.  (Fig.  61.)  It  is  strong,  of  small  diameter,  is  readily 
rendered  sterile,  and  is  easily  handled.  It  does  not  lose  its  slight- 
stiffness  when  soaked  in  solutions,  and  consequently  does  not  ravel 


NON-ABSORBABLE    LIGATURE    MATERIAL 


101 


as  does  silk  when  wet.  It  is  destined  to  displace  silk  for  intestinal 
work.  The  only  objection  to  its  use  is  that  it  is  not  absorbed.  It 
is  sterilized  by  boiling,  and  may  be  boiled  for  a  practically  in- 
definite period  of  time  without  being  damaged.     Like  anything 


Fig.  59. — Braided  White  Silk  in  Hermetically  Sealed  Glass  Tube. 

which  will  stand  heat,   it  is,   of  course,   absolutely  sterile   after 
boiling. 

It  may  be  boiled  and  preserved,  like  silk,  in  a  glass  jar  (Fig. 
48)  or  glass  tubes  (Fig.  59)  submerged  in  bichlorid  of  mercury 


Fig.  60. — Twisted  Iron-dyEd  Silk  in  Hermetically  Sealed  Glass  Tube. 

solution,  1-1,000,  or  placed  in  alcohol.  It  is  advised  that  it  be 
boiled  with  the  instruments  immediately  before  operating.  Twenty 
minutes  of  boiling  in  a  1  per  cent,  solution  of  sodium  carbonate 
is  sufficient  for  the  purpose. 


Fig.  61. — Pagenstecher  Thread. 


Its  use  is  especially  indicated  in  gastroenterostomy  by  sewing 
only,  and  in  entroenterostomy  where  a  long,  continuous  suture 
is  employed.  The  large  number  of  punctures  made  during  the 
sewing,  each  time  drawing  the  suture  through  tissues,  is  likely  to 


102 


SUTURE   AND   LIGATURE  MATERIAL 


weaken  silk  at  a  given  point  and  just  as  the  suturing  is  about  com- 
pleted the  suture  breaks.  This  necessitates  a  replacement  of  the 
entire  suture,  a  very  undesirable  accident.  The  greater  strength 
of  the  Pagenstecher  thread  renders  this  occurrence  exceedingly 
unlikely.  This  feeling  of  security  on  the  part  of  the  surgeon  en- 
genders a  certain  complacency  which  is  not  disagreeable.  On  the 
whole,  the  Pagenstecher  thread  is  an  exceedingly  valuable  material 
for  the  purpose  mentioned. 

HORSE  HAIR 

Horse  hair  is  used  for  apposing  wounds  of  the  face  and  neck 
where  cosmetic  effect  is  an  important  consideration.  It  is  also 
used  in  repairing  hare  lip.  The  hair  is  extracted  from  the  tail 
of  the  horse,  is  washed  in  soap  and  water,  and  boiled  for  an  hour 
in  95  per  cent,  alcohol,  when  it  is  ready  for  use.     It  can  be  pre- 


Fig.  62. — Silver  Wire  in  Hermetically  Sealed  Glass  Tube. 


served  in  a  glass  jar  (Fig.  48)  or  glass  tubes  (Fig.  59)  submerged 
in  alcohol. 

It  is  very  easily  handled,  does  not  ravel,  and  because  of  its 
fineness  may  be  threaded  on  exceedingly  small  needles.  The  lat- 
ter qualification  means  small  and,  at  times,  quite  invisible  stitch- 
hole  scars.  Its  black  color  renders  it  easily  located  when  about  to 
be  removed. 

SILVER  AND   GOLD   WIRE 

Silver  and  Gold  wire  are  used  to  hold  in  apposition  fragments 
of  bone.  Silver  wire  is  most  commonly  used  for  the  purpose.  It 
has,  on  occasions,  been  used  to  hold  soft  parts  in  apposition,  such 
as  the  cervix  uteri  after  trachelorrhaphy,  and  as  a  deep  suture  fol- 
lowing plastic  repair  of  the  female  perineum.  Other  material 
has,  however,  taken  its  place  in  almost  all  instances  except  for  the 


NON-ABSORBABLE    LIGATURE    MATERIAL  103 

purpose  of  holding  together  divided  bones.  Gold  wire  is  at  times 
used  in  plastic  repair  of  the  nose. 

Silver  wire  is,  of  course,  readily  sterilized  by  boiling.  Twenty 
minutes  of  boiling  in  a  soda  solution,  such  as  is  used  for  sterilizing 
instruments,  is  sufficient  to  achieve  the  purpose. 

It  is,  perhaps,  at  times  found  convenient  to  preserve  the  wire 
in  much  the  same  manner  as  silk-worm  gut.  In  these  instances  it 
may,  after  boiling,  be  placed  in  hermetically  sealed  glass  tubes 
(Fig.  62)  and  treated  as  this  class  of  vehicles  all  are,  immediately 
before  the  operation. 


CHAPTEE    V 
WATER   AND  CLEANSING  SOLUTIONS 

Water:  Sterilization  of  water — Apparatus  for  sterilization  of  water — Outfit 
for  sterilization — Handling  of  water  during  operations. 

Antiseptic  Solutions:  Carbolic  acid — Mercury — Zinc  chlorid,  etc. — Thiersh's 
fluid — Peroxid  of  hydrogen — -Plain  sterile  water — Saline  solution. 

WATER 
STERILIZATION   OF   WATER 

Absolutely  sterile  water  is  a  necessity  in  operative  teclmic. 
It  is  obtained  with  greater  difficulty  than  would  appear.  Chem- 
ically pure  water  for  lavage  and  cleansing  is  not  a  necessity, 
though  when  water  is  to  be  used  to  hold  chemical  agents  in  solu- 
tion it  had  best  be  chemically  pure  to  obviate  chemical  precipita- 
tion and,  perchance,  the  introduction  into  wounds  or  the  circula- 
tion of  insoluble  chemical  agents  which  may  act  as  foreign  bodies. 

Water  in  which  all  microorganisms  are  destroyed  in  the  vessel 
from  which  it  is  drawn  for  immediate  use  achieves  this  object. 
All  other  methods  of  sterilization  are  faulty. 

Distilled  water  has  the  advantage  of  being  transparent,  though 
the  apparatus  necessary  for  distillation  is  not  readily  kept  sterile, 
and  the  simple  distillation  of  water  is  not  sufficient  for  the  pur- 
pose of  sterilization. 

Muddy  water  may  be  sterile,  though  the  foreign  bodies  may 
be  removed  by  filtration,  and,  indeed,  should  be.  However,  in  an 
emergency  it  would  be  wiser  to  use  cloudy  sterilized  water  than 
to  act  on  the  notion  that,  because  water  is  clear,  it  is  clean.  Where 
water  is  used  to  fill  cavities  for  examination,  such  as  in  cystoscopy, 
distilled  and  sterilized  water  is  advantageous.  In  large  hospitals 
and  institutions  distilling  plants  are  installed  and  a  large  quan- 
tity of  distilled  water  is  constantly  available.  If  this  be  sterilized 
it  is  of  signal  service  for  surgical  purposes. 

104 


WATER 


105 


APPARATUS   FOR   STERILIZATION   OF   WATER 

For  the  purpose  of  sterilizing  water  two  kinds  of  apparatus  are 
available.  A,  one  which  sterilizes  water  at  the  boiling  point,  212° 
F.,  and  B,  one  which  sterilizes  water  at  a  temperature  higher  than 
the  boiling  point.     The  latter  is  the  more  certainly  effectual. 

For  ordinary  purposes,  in  minor  or  emergency  surgery,  water 
boiled  in  a  clean  vessel  for  twenty  minutes  and  used  immediately 
is  practically  sterile.  Indeed,  a 
tin  kitchen  boiler  placed  on  a  gas 
stove  and  the  contents  boiled  as 
stated  will  answer  the  purpose. 
However,  for  office  work  and  in 
smaller  institutions  and  dispen- 
saries, the  apparatuses  shown  in 
Figs.  63  and  64  are  recommended. 

Fig.  63  shows  an  apparatus 
exceedingly  useful  for  physician's 
office  use,  more  especially  for  the 
genito-urinary  cases.  The  appa- 
ratus sterilizes  the  water  abso- 
lutely and  is  constructed  to  with- 
stand pressure  of  50  pounds  to  the 
square  inch.  To  fill,  the  water  is 
poured  into  the  funnel  and  the 
quantity  noted  on  the  water  gauge. 
The  burner  beneath  is  then  lighted 
and  the  water  heated  until  steam 

issues  from  the  funnel,  when  the  valve  is  screwed  down.  Suffi- 
cient steam  pressure  will  then  be  generated  to  blow  off  safety  valve 
which  is  set  at  15  pounds  or  250°  F.  This  temperature  is  main- 
tained for  fifteen  to  twenty  minutes  for  absolute  sterilization.  The 
capacity  of  the  apparatus  should  be  about  two  gallons. 

Fig.  64  shows  an  apparatus  similar  to  Fig.  63,  except  that  the 
water  is  not  subjected  to  pressure.  If  the  contents  be  heated  to 
boiling  for  twenty  minutes,  the  water  is  practically  sterile,  but 
this  apparatus  is  not  so  certain  in  its  results  as  the  former  (Fig. 
63). 

The  objection  to  the  steam  pressure  sterilizer  (Fig.  63)  is 
that  the  water  is  liable  to  be  either  too  hot  or  too  cold  when  about 


Fig.  63. — Apparatus  for  Steriliz- 
ing Water  under  Pressure, 
for  Use  in  Surgeon's  Office 
or  Small  Dispensary. 


106 


WATER   AND   CLEANSING   SOLUTIONS 


to  be  used.  This  is  obviated  in  the  apparatus  shown  in  Fig.  65 
by  a  coil  within  the  tank,  which  may  be  connected  with  the  cold 
water  tap.  In  this  way  the  temperature  of  the  water  may  be 
modified,  its  range  being  indicated  by  a  thermometer  affixed  to 

the  apparatus.  This  apparatus  is  de- 
vised for  office  use  and  answers  the 
purpose  very  well. 

Neither  of  these  apparatuses  per- 
mits sufficient  elasticity  with  respect  to 
the  adjustment  of  the  temperature  of 
water,  which  is  essential  to  the  best 
possible  work.  The  contingencies  met 
in  operative  work  are  well  met  by  the 
apparatus  shown  in  Figs.  65  and  66. 

The  hydrant  water  supply  is  di- 
rectly connected  to  filter  M  at  point  E. 
The  filter  itself  consists  of  a  natural 
porous  stone  bougie  which  can  be  taken 
out  of  the  metal  mantle  for  purpose  of 
cleaning  and  be  placed  back  into  posi- 
tion by  releasing  top,  which  is  held 
tight  to  cylinder  by  a  heavy  metal 
clamp  N. 

There  are  two  outlets  F  F  for  the 
filtered  water  leading  into  the  two 
tanks ;  both  are  provided  with  a  valve. 
These  valves  may  both  be  opened  at 
the  same  time,  or  one  tank  may  be 
filled  first  and  then  the  other.  As 
soon  as  the  gauge  glasses  K  K  on  the 
sides  of  tanks  indicate  that  the  latter 
are  filled  as  far  as  gauge  glasses  regis- 
ter, the  water  has  to  be  turned  off  by  closing  the  respective  valves 
leading  from  filter  to  tank.  When  both  tanks  are  filled,  first  shut 
off  water  supply  valve  E  leading  to  filter,  and  then  close  valves 
F  F  leading  from  filter  to  tanks. 

The  heating  of  the  water  in  the  tanks  is  now  begun.  The 
steam  pressure  safety  valve  W,  on  dome  top  of  tanks,  is  always 
get  at  15  pounds  pressure,  and  as  soon  as  this  point  is  reached  it 


Fig.  64.  —  Water  Sterilizer 
Suitable  for  Emergency 
Service. 


WATER 


107 


will  blow  off  steam  and  maintain  a  boiling  temperature  of  250° 
F.,  the  equivalent  of  15  pounds  steam  pressure.  Water  has  to 
be  kept  at  this  boiling  point  for  from  twenty  to  thirty  minutes, 
whereupon  the  gas  or  petroleum  heaters  G  G  have  to  be  turned 


Fig.  65. — Apparatus  for  Sterilizing  and  Cooling  Sterile  Water  under 
Pressure,  for  Use  in  Hospitals  and  Large  Dispensaries. 


out  or,  in  the  case  of  steam-heated  apparatus,  the  high-pressure 
boiler  steam  be  shut  off  by  closing  valves  A  A  and  B  B. 

Contents  of  the  tanks  can  now  be  considered  absolutely  sterile, 
but  the  water  is  too  hot  to  be  available  for  immediate  use.  In 
order  to  facilitate  an  instantaneous  cooling  of  the  hot  sterilized 
water,  a  cooling  coil  has  been  arranged  in  one  of  tanks  marked 


(TOr^CW 


a 


KNY-SCHEERERCQl 
N.Y 


Fig.  66. — Sectional  View  of  Apparatus  Shown  in  Fig.  65 


108 


WATER  109 

"Cold"  (Fig.  65).  It  consists  of  a  heavily  tinned  copper  coil, 
placed  in  the  upper  part  of  the  tanks,  into  which  is  turned  a  flow 
of  cold  hydrant  water,  by  admitting  water  at  point  D  and  provid- 
ing for  water  off-flow  at  point  C.  Within  from  ten  to  twenty  min- 
utes the  boiling-hot  sterile  water  in  the  cylinder  marked  "  Cold  " 
will  have  been  cooled  clown  to  within  a  few  degrees  above  that  of 
the  hydrant  water  used  for  cooling.  The  sterilized  water  contained 
in  this  tank  can  be  nsed  immediately  and  be  tapped  by  faucet  in 
front.  Water  and  container  both  are  strictly  sterile,  and  to  main- 
tain this  state  of  absolute  sterility,  an  air-filtering  valve  XX, 
filled  with  absorbent  cotton  is  placed  on  dome  top  of  each  tank. 
As  water  is  drawn  out  of  tanks,  the  air  enters  the  latter  through 
the  bacteriological  filter  X,  the  absorbent  cotton  in  which  should 
be  renewed  frequently. 

Tank  marked  "  Hot  "  (Fig.  65)  has  no  cooling  coil,  but  its 
contents  are  allowed  to  gradually  cool  down.  By  drawing  from 
both  tanks,  sterile  water  of  any  desired  degree  of  temperature  can 
be  obtained  by  mixing.  If  temperature  of  sterilized  water  should 
become  too  low,  the  heating  medium  may  be  started  to  raise  it  to 
the  desired  point,  which  can  be  controlled  by  consulting  a  ther- 
mometer H  in  front  of  each  tank,  and  accordingly  regulating 
heat  supply. 

Attention  has  already  been  called  to  the  fact  that  hydrant 
water,  even  though  it  may  be  crystal  clear  after  passing  through 
the  filter,  will  become  cloudy  when  being  boiled  under  high  tem- 
perature. Gradually  the  cloudiness  will  form  precipitates  which 
settle  on  the  bottom  of  the  tank.  To  draw  off  these  precipitates 
a  faucet  is  provided,  flush  with  the  lowest  point  in  bottom  of  the 
cylinder,  while  the  draw-off  cock  for  sterile  water  for  surgical 
purposes  in  front  of  the  tank  is  about  two  inches  above  bottom. 

To  clean  the  sterilizer  tanks  thoroughly  (which  should  be 
done  every  three  months),  remove  filtering  stone  from  metal 
jacket  M,  fill  the  latter  with  sal  soda  and  proceed  exactly  as  if 
you  were  sterilizing  water.  The  tanks  should  then  be  emptied 
while  under  pressure  by  opening  the  flushing  valves  under  the 
tanks. 

Special  attention  is  drawn  to  the  fact  that  safety  valves  W  W 
are  always  set  at  15  pounds  pressure  per  square  inch  when  the 
sterilizers  are  ready  for  use.    They  should  never  be  tampered  with 


110 


WATER   AND   CLEANSING   SOLUTIONS 


by  inexperienced  hands,  as  by  tightening  the  set  screws  the  amount 
of  steam  pressure  in  tank  may  be  increased  beyond  the  point  of 
safety. 


OUTFIT    FOR   STERILIZATION 


Fig.  67  shows  a  plan  of  installing  a  complete  sterilizing  plant, 
as  is  employed  in  a  large  hospital.  The  outfit  consists  of  a  dress- 
ing sterilizer  A,  a  water  sterilizer  B?  an  instrument  sterilizer  C, 
an  utensil  sterilizer  for  the  purpose  of  subjecting  to  steam  press- 


a  b  c  d  e 

Fig.  67. — Complete  Sterilizing  Outfit  Assembled  for  Use  lx  Large 

Hospital. 

lire  pans,   basins,   irrigation  containers,    etc.,   D,   and   a   blanket 
warmer  E. 

This  plan  provides  for  the  necessary  heat  to  be  drawn  from 
either  the  steam  power  plant  of  the  building  or  from  gas  Bunsen 
burners  attached  directly  to  the  various  apparatuses.  The  former 
plan  is  effective,  and  the  necessary  temperature  is  quickly  avail- 
able. However,  the  fact  that  steam  power  plants  are  rarely  in- 
stalled in  duplicate,  even  in  the  largest  hospitals,  and  that  at 
times  the  boilers  are  shut  down  for  repair  and  cleansing,  sug- 
gests that  the  direct  heating  plan  has  its  redeeming  features. 
Also,  the  necessity  of  leading  the  steam  through  the  hospital 
building  during  the  summer  months  is  objectionable,  especially 
in  regions  where  the  climate  is  very  warm.  If  feasible,  the  plant 
should  be  set  up  in  a  room  adjoining  the  operating  room,  with 


WATER 


111 


the  view  of  obviating  the  enervating  influence  of  excessive  tem- 
perature upon  the  patient  and  the  surgeon  during  operations. 

As  stated  farther  on,  the  instrument  and  utensil  sterilizer 
may  be  placed  in  the  operating  room,  so  that  immediate  steriliza- 
tion of  appliances  during  the  operation  is  possible  without  the 
necessity  for  the  assistant  in  charge  of  this  portion  of  the  work 
leaving  the  zone  of  operation. 

The  sterile  water  tanks  are  readily  connected  with  the  operat- 
ing room  by  piping  the  outlets  through  the  partition  separating 
the  chamber  used  for  the  purpose  from  the  operating  room. 

The  utensil  sterilizer,  instrument  sterilizer,  and  the  dressing 
sterilizer  are  described  under  separate  heads. 

Tig.  68  shows  a  diagrammatic  scheme  of  the  water,  instrument, 


DREssims  Sterilizer 


Hater  Sterilizer 


Ihstrvment  Sterilizer      Utensil  Sterilizer.  Blanket  Warmer. 


B  B      ff  ff 


Ground    Plan- 


Fig.  68. — Plan  of  Sterilizing  Plant  for  Use  in  Large  Hospitals. 


utensil  sterilizer  and  blanket  warmer.  The  upper  diagram  shows 
the  plant  in  profile  section,  the  lower  in  transverse  section.  This 
plant  is  arranged  for  obtaining  heat  from  either  the  steam  power 
plant  or  from  gas  Bunsen  burners.  This  arrangement  is  very  de- 
sirable, overcoming,  as  it  does,  the  objections  to  employment  of  the 
single  source  of  heat  mentioned  above. 


112 


WATER   AND   CLEANSING   SOLUTIONS 


This  plant  is  an  elaborate  one,  and  has  a  large  field  of  use- 
fulness. It  illustrates  the  principle  involved,  and  in  instances 
where  this  refinement  is  not  available,  forms  the  basis  of  modifi- 


Fig.  69. — Combined  Water,   Dressing  and  Instrument  Sterilizers  Conven- 
iently Assembled  for  Use  in  Surgeon's  Office. 

cations  in  detail  which  may  be  necessary  as  the  outcome  of  cir- 
cumstances. 

For  use  in  the  surgeon's  office  the  outfit  shown  in  Fig.  69  is 
very  useful.     It  is  in  all  respects  similar  to  that  described  with 


WATER 


113 


Fig.  70. — Convenient  Arrangement  of  Pitchers  Containing  Sterile  Water 
and  Solutions  for  Use  During  the  Operation. 


regard  to  the  dressing,  water,  and  instrument  sterilizers,  except 
that  it  is  arranged  on  a  stand  to  conserve  space  and  subserve 
availability.  In  this 
connection  it  is  proper 
to  state,  as  applies  also 
to  the  hospital  outfit, 
that  modification  of  ap- 
paratus is  permissible, 
provided  the  principles 
involved  are  adhered  to. 
The  water  tanks  are 
arranged  to  sterilize  the 
contents  in  each  tank, 
one  of  which  is  fitted 
with  the  cooling  coil 
(Fig.  G6).  Each  tank 
has  a  capacity  of  about 
six  gallons,  and  the 
dressing  sterilizer  is  of 
sufficient  capacity  to 
sterilize  at  one  sitting 
enough  material  to  suf- 
fice for  a  single  major 
operation,     or     enough 


Fig.  71. — Method  of  Handling  Sterile  Water 
or  Solution  in  Pitcher  without  Contami- 
nating Contents. 


114 


WATER   AND   CLEANSING   SOLUTIONS 


sponges,  towels,  gauze,  etc.,  for  office  use  for  several  days.  The 
instrument  boiler  is  8  inches  wide,  6  inches  deep,  and  15  inches 
in  length,  giving  an  internal  capacity  sufficient  for  all  practical 
purposes. 

HANDLING  OF  WATER  DURING   OPERATIONS 

Water  is  handled  during  operations  by  the  non-sterile  nurse 
or  attendant.     Whatever  the  apparatus  employed  for  sterilizing 


Fig.  72. — Drawing  Sterile  Water  without  Risk  of  Contamination. 

water  for  surgical  purposes  may  be,  be  it  either  a  tin  wash  boiler, 
a  basin,  or  an  elaborate  plant,  such  as  described,  it  is  essential  to 
avoid  contamination  during  transportation  from  the  receptacle 
used  to  the  wound. 

The  attendant  who  handles  sterile  material  during  an  opera- 
tion cannot  safely  handle  pitchers,  irrigators,  etc.,  and  although 
this  matter  is  taken  up  under  operating-room  technic,  attention 
is  called  to  it  in  this  connection.     Perhaps  the  most  desirable  and 


WATER  115 

elastic  method  of  handling  water  is  in  pitchers.  The  pitchers  are 
sterilized  by  boiling  (page  151),  and  arranged  on  a  table  of  con- 
venient size.  It  is  preferable  to  have  available  three  pitchers  of 
white  enamel   for  the  purpose,  the  larger  two  for  pouring  the 


V     1 

^  i  m 

■c 

ft 

M  m 

\     1 

BK*"1WM" 

Fig.  73. — Wrong  Way  to  Hold  Basin  Containing  Sterile  Water  or 

Solution. 

contents  on  the  field  of  operation,  and  the  second,  a  somewhat 
smaller  one,  for  replenishing  the  larger  two.  The  larger  ones 
should  hold  a  gallon,  and  the  smaller  half  that  quantity. 

A  convenient  arrangement  of  pitchers  is  shown  in  Fig.  70. 
It  will  be  seen  that  each  pitcher  is  covered  with  a  sterile  towel 
fastened  to  the  handle  of  the  pitcher,  and  has  a  safety  pin  at- 
tached at  the  lip  side  of  the  pitcher.  In  order  to  fill  the  vessel, 
the  nurse  takes  the  pitcher  by  the  handle,  grasps  the  safety  pin 
10 


116  WATER  AND   CLEANSING   SOLUTIONS 

with  the  other  hand  (Fig.  71),  and  throws  the  towel  hack  over 
the  hand  on  the  handle.  The  hand  released  from  the  safety  pin 
now  turns  the  faucet  of  the  water  tank,  and  the  pitcher  is  filled. 
At  no  time  do  the  hands  come  in  contact  with  the  water  or  with 


Fig.  74. — Proper  Way  of  Holding  Basin  with  Sterile  Contents. 

apparatus  in  contact  with  water  (Fig.  72).  When  the  contents 
of  the  pitcher  are  to  he  applied  to  the  operation  field  the  same 
procedure  as  shown  in  Fig.  71  is  employed. 

In  the  event  of  a  tin  hoiler  or  other  apparatus  being  used,  the 
hand  corresponding  to  the  one  turning  the  faucet  is  employed  in 
tilting  the  receptacle.  If  a  basin  be  used,  care  should  be  taken 
not  to  allow  the  thumbs  to  encroach  on  the  inside  (Fig.  73),  but 
the  basin  must  be  held  as  shown  in  Fig.  74.     The  temperature  of 


ANTISEPTIC   SOLUTIONS  117 

water  and  watery  solutions  employed  for  surgical  purposes  should 
not  be  left  to  guessing.  For  purposes  of  accuracy  an  ordinary 
bath  thermometer  is  of  practical  use  (Fig.  42).  The  apparatus 
is  sterilized  by  prolonged  immersion  in  mercuric  chlorid  solu- 
tion 1  in  1,000.  The  thermometer  is  placed  in  the  pitcher  or 
other  apparatus  by  lifting  the  sterile  towel  by  the  safety  pin. 
The  nurse  handles  the  thermometer,  carefully  avoiding  contact 
with  all  except  the  handle,  which  it  is,  of  course,  not  necessary  to 
place  in  the  pitcher. 

ANTISEPTIC   SOLUTIONS 

Solutions  destined  to  destroy  bacteria  by  chemical  action  are 
of  doubtful  utility.  Chemical  agents  of  sufficient  strength  to  de- 
stroy bacteria  have  a  deleterious  effect  upon  tissue.  As  a  general 
rule,  solutions  containing  antiseptics  require  one  hour  in  which  to 
destroy  bacteria.  However,  these  agents  inhibit  the  growth  of 
bacteria,  and  when  used  in  conjunction  with  other  means  of  steril- 
ization have  a  distinct  place  in  surgical  technic.  The  most  valu- 
able function  antisepsis  and  antiseptic  solutions  fill  is  in  the 
disinfection  of  instruments  and  apparatus  which  come  in  contact 
with  the  wound.  They  are  of  service  in  cleansing  the  skin  of  the 
patient  and  the  surgeon's  and  assistant's  hands. 

CARBOLIC   ACID 

Carbolic  acid,  mentioned  first  by  right  of  seniority,  is  very 
frequently  employed  for  the  purpose.  It  is  cheap,  readily  obtained, 
and  in  strong  solution  quite  effective.  Since  it  has  been  deter- 
mined that  alcohol  neutralizes  its  caustic  effect  when  the  latter  is 
applied  early  after  the  former,  it  is  used  extensively  undiluted. 
When  pure  carbolic  acid  is  applied  to  a  surface  it  must  be  dis- 
placed by  a  large  amount  of  alcohol  within  a  few  moments  after 
its  application.  If  too  long  a  time  be  allowed  to  elapse,  the  alcohol 
is  no  longer  effectual.  It  is  also  necessary  to  use  a  large  quantity 
of  alcohol  to  accomplish  the  purpose.  In  solution,  carbolic  acid  is 
used  in  the  following  proportion : 

Carbolic  acid  crystals 1  part. 

Alcohol 1   part. 

Sterile  water 20  parts. 


118  WATER  AND   CLEANSING   SOLUTIONS 

In  this  proportion  carbolic  acid  is  used  for  washing  the  skin  and 
for  immersion  of  instruments  during  an  operation  in  an  infected 
case.  Prolonged  contact  with  the  hands  constringes  the  tissues, 
produces  anesthesia,  and  is  not  infrequently  followed  by  annoy- 
ing dermatitis.  For  purposes  of  cleansing,  weaker  solutions  are 
used,  though  not  as  effective  as  the  stronger. 

Sterile  water 40  parts. 

Alcohol 1  part. 

Carbolic  acid  crystals 1   part. 

Carbolic  acid  solutions  have  a  certain  field  of  usefulness,  es- 
pecially under  conditions  where  asepsis  is  not  readily  obtained. 
Occasional  lavage  of  the  hands  or  soiled  instruments  in  a  solution 
of  carbolic  acid  during  the  operative  procedure  is  a  useful  indul- 
gence. Towels  wrung  out  in  a  solution  of  carbolic  acid,  1  in  40, 
are  used  to  cover  portions  of  the  body  contiguous  to  the  operation 
field  and,  while  not  intended  to  take  the  place  of  towels  sterilized 
by  heat,  are  valuable  supplementary  agents  during  prolonged 
operations  undertaken  for  the  relief  of  infection.  It  is  compre- 
hensible that  a  towel  sterilized  by  heat  is  more  readily  contami- 
nated by  contact  with  infective  material  than  one  which  is  satu- 
rated with  carbolic  acid  solution  after  heat  sterilization. 

During  the  operation,  instruments  are  placed  on  the  parts  sur- 
rounding the  operation  field  and,  although  these  areas  are  covered 
with  sterile  towels,  it  is  not  amiss  to  cover  these  with  towels  treated 
as  mentioned,  at  intervals.  This  applies  equally  well  to  antisep- 
tics other  than  carbolic  acid.  In  operations  undertaken  under  con- 
ditions where  a  large  supply  of  sterile  towels  is  not  available,  such 
as  not  infrequently  obtains  in  private  practice  in  the  country,  this 
should  be  borne  in  mind,  and  perhaps  will  meet  very  effectually 
the  indications  during  an  emergency. 

For  practical  purposes  a  concentrated  solution  of  carbolic  acid 
is  kept  in  a  stock  bottle  and  a  certain  quantity  of  this  added  to  the 
water  in  accordance  with  the  capacity  of  the  vessel  employed  and 
the  strength  of  the  solution  it  is  desirable  to  use  in  a  given  instance. 
It  is  to  be  borne  in  mind  that  carbolic  acid  is  heavier  than  water 
and  does  not  dissolve  rapidly.  The  water  and  acid  should  be  thor- 
oughly mixed  before  using  the  solution,  to  avoid  collection  of  the 
latter  at  the  bottom  of  the  receptacle,  thus  preventing  contact  of 


ANTISEPTIC   SOLUTIONS  119 

the  acid  with  the  wound  as  the  last  of  the  mixture  comes  in  con- 
tact with  it.  Especially  is  this  true  when  carbolic  acid  solutions 
are  used  in  an  irrigator.  If  the  carbolic  acid  be  poured  into  the 
irrigator  last,  after  the  water,  it  gravitates  to  the  rubber  tube  and 
is  expelled  first  in  concentrated  form.  Under  these  conditions  the 
solution  is  best  made  in  a  pitcher  first,  and  after  being  dissolved 
poured  into  the  irrigator. 

MERCURY 

Mercury  is  perhaps  the  most  universally  used  antiseptic.  It 
is  employed  in  solution  of  1  in  1,000  to  1  in  10,000,  according  to 
the  purpose  for  which  it  is  designed.  It  is  cheap,  effective,  in- 
odorous, and  will  keep  indefinitely.  It  is  poisonous,  however,  and 
should  not  be  left  in  contact  with  raw  surfaces  nor  allowed  to  stay 
in  large  cavities  for  fear  of  mercurialization.  It  is  not  uncommon 
to  see  salivation  and,  indeed,  even  sloughing  of  the  oral  mucosa 
follow  its  indiscriminate  use  in  wounds  of  large  area.  The  salts 
of  mercury,  chiefly  the  bichlorid,  are  used  combined  with  sodium 
bicarbonate  to  avoid  chemical  change  in  the  salt  and  to  enhance 
solubility. 

For  use,  the  salts  are  kept  in  concentrated  solution  to  be  diluted 
to  the  required  extent  at  the  time  of  operating.  However,  the 
most  convenient  form  is  that  of  a  tablet  containing 

Mercury  bichlorid grs.   1h 

Sodium  bicarbonate grs.   7 A 

The  sodium  carbonate  may  be  replaced  with  sodium  borate  or 
ammonium  chlorid. 

One  of  these  tablets  to  a  pint  of  water  makes  a  solution  of 
1  in  1,000.  The  modification  of  relationship  to  the  solvent  to  con- 
form to  the  necessities  is  purely  a  matter  of  mathematics.  The 
manufacturers  put  the  tablet  up  together  with  a  small  amount  of 
aniline  dye,  which,  when  the  tablet  dissolves,  renders  the  solution 
blue.  This  avoids  mistakes  in  identifying  the  solution  during  the 
operation,  differentiating  it  from  others  prepared  at  the  same  time. 

Again,  on  occasions,  the  white  bichlorid  of  mercury  tablets 
have  been  mistaken  by  children  for  confections  and  swallowed 
with  fatal  result.  It  is  advised  that  the  colored  tablet  be  employed. 
Corrosive  sublimate  is  the  form  of  mercury  most  generally  used. 


120  WATER   AND   CLEANSING   SOLUTIONS 

It  is  effective,  as  stated,  but  has  an  exceedingly  pernicious  effect 
upon  instruments.  To  obviate  this  the  mercuric  iodid  is  used, 
which  is  quite  devoid  of  deleterious  influences  in  this  regard. 

Mercuric  iodid %  gr. 

Sod.  bicarb 16  grs. 

One  tablet  dissolved  in  four  ounces  of  water  makes  a  1  in  5,000 
solution. 

Mercuric  iodid  in  1  in  5,000  solution  is  as  effective  in  destroy- 
ing bacteria  as  bichlorid  of  mercury  in  a  solution  of  1  in  1,000. 
It  does  not  coagulate  albumin  and  does  not  corrode  instruments. 

The  mercuric  iodid  disk,  or  tablet,  is  the  outcome  of  work  done 
by  McClintoch. 

Cumston  advises  the  following: 

Mercury    cyanid gm.    .50. 

Sodium  borate  c.  p gm.  1.0. 

This  tablet  dissolves  very  readily  and  is  regarded  as  more  certainly 
effective  than  either  the  bichlorid  or  iodid  of  mercury.  One  tablet 
to  a  pint  of  water  makes  a  solution  of  1  in  1,000. 

ZINC    CHLORID,    ETC. 

Solutions  of  chlorid  of  zinc,  1  in  15;  iodin,  1  in  500;  sulpho- 
carbolate  of  zinc,  1  in  80 ;  a  saturated  solution  of  boracic  acid, 
sulphurous  acid,  1  to  2,  or  a  saturated  solution  of  iodoform  in  ether 
have  been  used  for  cleansing  wounds.  They  are,  however,  rarely 
used  for  cleansing  the  operation  field,  and  while  possessed  of  some 
antiseptic  virtues,  are  not  by  any  means  as  effectual  in  preventing 
infection  as  the  agents  mentioned. 

Their  particular  field  will  be  discussed  in  the  treatment  of 
postoperative  wound  infection. 

TRTERSH'S    FLUID 

Thiersh's  Fluid  is  composed  of  one  grain  of  salicylic  acid  and 
six  grains  of  boric  acid  to  the  ounce  of  water.  As  can  be  seen  from 
its  composition,  it  is  not  antiseptic.  It  is  used  for  cleansing  ser- 
ous and  mucous  membranes,  such  as  the  peritoneum,  joint  cavities, 
the  conjunctiva,  the  mucosa  of  the  mouth,  etc.     It  is  best,  made 


ANTISEPTIC   SOLUTIONS  121 

freshly  just  before  using,  the  powder  being  arranged  so  as  to  have 
sufficient  of  the  soluble  ingredients  to  make  a  pint  of  the  solution 
in  the  proportions  mentioned,  i.e.,  16  grs.  of  salicylic  acid  and  96 
grs.  of  boric  acid  are  placed  in  a  packet,  and  when  dissolved  in  a 
pint  of  sterile  water  make  the  proportion  stated. 

PEROXID    OF    HYDROGEN 

Peroxid  of  Hydrogen,  while  not  employed  to  cleanse  the  field 
of  operation  in  clean  cases,  should  be  on  hand  to  neutralize  in- 
fective substances  met  in  operations  on  infected  cases.  Peroxid 
of  hydrogen  owes  its  bactericidal  qualities  to  its  deoxidizing 
properties. 

It  consists  of  water  with  an  added  atom  of  oxygen.  The  lat- 
ter is  but  unstably  associated  and  is  apt  to  be  lost  if  the  container 
be  not  very  firmly  stoppered.  When  in  contact  with  the  wound, 
an  active  effervescence  takes  place,  which  is  believed  to  cause  pene- 
tration of  the  liquid  into  remote  portions  of  the  operative  field,  and 
to  mechanically  dislodge  offending  substances,  at  the  same  time 
acting  as  a  germicide.  Heat  destroys  its  efficacy.  It  is,  therefore, 
slightly  warmed  before  use,  by  immersing  the  container  in  hot 
water  for  a  short  time.  When  once  the  container  has  been  opened, 
the  contents  soon  become  ineffective,  and  it  is  recommended  that 
small  receptacles  be  on  hand  which  contain  the  amount  to  be  used 
at  a  sitting  and  to  conserve  economy. 

When  applied  to  cavities  with  small  openings,  provision  should 
be  made  for  ample  return  of  the  liquid,  as  the  effervescence  is  likely 
to  invade  surrounding  healthy  tissue  and  thus  infection  be  spread. 
It  is  used  either  pure  or  diluted  25  to  50  per  cent,  with  sterile 
water.  It  is  only  moderately  germicidal  in  the  pure  state.  It  is 
advised  that  it  be  used  undiluted.  As  an  antiseptic  it  does  not  take 
the  place  of  carbolic  acid  nor  mercuric  chlorid.  It  is  useful,  how- 
ever, in  replacing  these  in  situations  where  the  antiseptics  men- 
tioned are  irritating. 

PLAIN  STERILE  WATER 

Sterile  water,  when  brought  in  contact  with  the  tissues,  ex- 
tracts from  them  certain  constituents  which  are  essential  to  it. 
Tissue  lavaged  with  plain  water  decolorizes.  This  is  true  both 
of  wounds  and  untraumatized  membranes.     The  part  that  the  in- 


122  WATER  AND  CLEANSING  SOLUTIONS 

organics  play  in  nutrition  is  unknown,  yet  it  is  proven  that  they 
are  essential  to  life.  Mechanically  sterile  water  is  an  ideal  cleans- 
ing fluid.  It  is  cheap,  may  be  obtained  in  indefinite  quantity,  and 
by  the  process  of  dilution  removes  infective  substances  from  the 
wound  or  normal  tissues.  However,  it  may  be  regarded  as  hungry 
for  something  to  hold  in  solution,  a  quality  which  is  objection- 
able in  surgical  technic.  If  this  quality  applied  only  to  infective 
material  it  would  be  an  exceedingly  fortunate  circumstance,  but  of 
course  water  is  not  selective  in  its  action  and  attacks  all  substances 
with  which  it  comes  in  contact,  few  of  which  effectually  withstand 
the  effect  of  its  prolonged  contact. 

SALINE   SOLUTION 

The  addition  of  salt  to  water  overcomes  to  a  considerable 
extent  the  objection  mentioned  in  connection  with  sterile  water. 
JSTo  doubt  some  mechanical  law  is  conserved  by  the  addition  of 
sodium  chlorid  to  sterile  water.  Saline  solution  is  made  by  dis- 
solving in  a  quart  of  filtered  water,  sterilized  at  a  temperature  of 
240°  F.,  a  dram  and  a  half  of  sodium  chlorid. 

The  sodium  chlorid  should  be  chemically  pure  and  sterile. 
The  latter  is  achieved  by  heat.  It  is  not  sufficient  to  sterilize  the 
salt  to  render  it  harmless.  All  foreign  substances  must  be  removed, 
and,  though  this  is  regarded  as  accomplished  by  using  the  chem- 
ically pure  preparation,  close  scrutiny  of  the  solution  shows  fine 
particles  suspended  in  the  mixture.  These  must  be  removed  by 
filtration  after  the  solution  is  made.  More  especially  is  this  true 
if  the  solution  is  to  be  used  for  intravenous  injection  or  hypoder-. 
moclysis  for  the  relief  of  shock  (page  259).  Having  on  hand 
a  concentrated  solution  in  sealed  tubes  (Fig.  40)  overcomes  all 
objections.  These  tubes  are  filled  with  solution  prepared  as  here 
recommended,  the  tubes  are  easily  sterilized  by  boiling,  and  are 
opened  and  the  contents  diluted  to  the  desired  extent  at  the  time 
of  the  operation,  with  sterile  water. 

Solutions  of  sodium  chloric!  may  be  permitted  to  remain  in 
contact  with  living  tissues  for  a  considerable  period  of  time  with- 
out deleterious  effect.  Of  course  the  solution  has  no  bactericidal 
qualities,  and  its  sphere  of  usefulness  is  quite  restricted  to  mechan- 
ical cleansing  of  the  operative  field.  It  is  largely  used  for  the 
purpose  of  lavaging  clean  wounds,  especially  those  which  involve 


ANTISEPTIC  SOLUTIONS  123 

invasion  of  serous  cavities  and  the  mucosa  of  the  stomach  and 
intestines. 

When  infection  is  present,  it  should  not  be  used  except  for  the 
occasional,  intermittent  removal  of  antiseptic  solutions.  It  is 
probable  that,  when  infection  exists,  the  prolonged  contact  of  saline 
solution  with  the  wound  area  promotes  infection,  on  the  ground 
that  a  condition  of  affairs  is  present  which  favors  bacterial  flora. 
The  lavage  of  normal  tissues  with  saline  solution  stimulates  nutri- 
tive processes,  a  conception  borne  out  by  the  fact  that  fertilization 
of  the  ova  of  the  lower  forms  of  animal  life  is  conserved  by  the 
presence  of  salt  solution.  The  latter  proposition  has  been  amply 
proven  by  painstaking  experimentation. 

It  is  quite  probable  that  in  surgery  the  use  of  large  quantities 
of  saline  solution  in  a  clean  wound  is  not  objectionable  on  this 
score,  yet  it  is  also  probably  true  that  the  tendency  has  been  to 
use  indiscriminately  a  new  method  of  cleansing  wounds  without 
proper  regard  for  the  actual  problem  presented  in  a  given  case. 
On  general  principles,  it  may  be  said  that  saline  solutions  should 
not  be  employed  for  the  purpose  of  cleansing  infected  wounds 
except  in  the  manner  stated  above,  and  in  all  instances  of  this  sort, 
it  should  be  finally  displaced  by  a  mildly  antiseptic  solution,  such 
as  carbolic  acid  or  corrosive  sublimate.  In  no  instances  should 
saline  solution  be  permitted  to  remain  in  an  infected  cavity,  proper 
and  useful  as  the  measure  may  be  when  infection  is  not  present. 


CHAPTER     VI 
THE   PREPARATION  OF  OPERATOR  AND  ASSISTANTS 

The  operating  suits — Cleansing  of  the  hands — Canton  flannel  gloves — Gowns — 
Gloves  during  operation — Caps  and  masks. 

It  seems  hardly  necessary  to  dwell  on  the  question  of  personal 
cleanliness  as  applied  to  practitioners  of  surgery.  However,  in 
private  practice  the  surgeon  not  infrequently  calls  upon  unskilled 
assistants  who  are  likely  to  assume  that  when  they  are  covered 
with  a  sterile  gown  during  the  operation,  all  other  precautionary 
measures  are  unnecessary.  Indeed,  it  not  infrequently  happens 
that  the  surgeon  slips  the  operating  gown  over  his  waistcoat  and 
regards  this  measure  as  sufficient  modification  of  attire  to  meet 
the  indications. 

In  this  connection  it  is  to  be  remembered  that  infection  is  a 
question  of  dosage  of  fertilization  and  the  gown  worn  during 
operating  soon  becomes  soiled  with  the  mixture  of  solutions  and 
secretions  from  the  operation  field.  These  soon  soak  the  gown, 
and  when  the  latter  is  permitted  to  come  in  contact  with  clothing 
worn  underneath,  the  hands  are  liable  to  come  in  contact  with 
the  soaked  area  and  thus  become  contaminated  from  infective 
material  beneath  the  gown. 

The  surgeon  and  assistants  should  take  a  complete  bath  at  a 
time  as  near  the  hour  set  for  operating  as  possible.  In  hospital 
practice  this  is  perfectly  feasible.  However,  in  private  practice, 
when  operations  are  performed  in  private  houses  or  in  the  coun- 
try, this  is  not  always  possible.  As  a  matter  of  discipline,  how- 
ever, the  surgeon  should  arrange  the  hour  of  taking  a  complete 
bath  in  such  a  way  as  to  permit  as  short  a  time  as  is  feasible  to 
elapse  between  the  taking  of  the  bath  and  the  operation. 

Particular  attention  should  be  paid  to  hair  and  beard  (page 
137). 

124 


THE   OPERATING  SUITS 


125 


THE   OPERATING   SUITS 


It  is  the  custom  in  private  practice,  and  it  not  infrequently 
happens  in  hospital  work,  for  the  surgeon  to  remove  his  coat, 
waistcoat,  and  shirt,  and  slip  a  rubber  apron  over  the  rest  of  the 
attire.  In  hospital  practice  this  is 
usually  the  habit  on  part  of  the  visit- 
ing- surgeon,  the  assistants  in  the  form 
of  the  house  staff  being  attired  in 
freshly  laundered  duck  suits.  The 
writer  advises  against  this  habit  on  the 
part  of  the  operator.  In  private  prac- 
tice the  method  of  procedure  stated  is 
carried  out  both  by  the  surgeon  and 
his  assistants,  chiefly  for  lack  of  other 
means  at  command  under  the  circum- 
stances. As  a  general  rule,  the 
method  is  effective  enough.  ISTo  one 
would  refrain  from  operating  because 
refinements  in  this  connection  were 
not  available.  However,  the  proper 
and  safe  attire  of  the  surgeon  and  as- 
sistants is  so  easily  obtained  and  trans- 
ported as  to  make  it  a  matter  of  but 
little  discomfort  to  take  the  necessary 
precautions. 

It  is  recommended  that  the  sur- 
geon disrobe  completely  and  replace 
the  street  clothes  with  a  canvas  or 
duck  suit,  consisting  of  loosely  fitting 
trousers  held  in  place  with  a  draw- 
string at  the  waist  and  a  sleeveless  blouse  tied  with  tapes  in  front. 
The  feet  should  be  incased  in  canvas  rubber-soled  shoes  (Fig.  75). 

This  outfit  is  easy  to  cleanse,  does  not  take  up  much  room, 
and  can  be  placed  in  the  bag  carrying  other  necessities.  It  is 
worn  next  the  skin,  and  when  the  operation  is  completed,  the 
surgeon  replaces  it  with  his  original  attire,  which  is  not  soiled,  is 
dry  and  clean,  and  promotes  a  feeling  of  comfort  and  cleanliness 
which  is  not  disagreeable.     ISTot  infrequently  the  surgeon  leaves 


Fig.  75. — Linen  or  Duck  Suit 
Worn  by  Surgeon. 


126  PREPARATION   OF   OPERATOR   AND   ASSISTANTS 

the  operating  room  with  wet  underwear  and  bespattered  shoes 
and  goes  out  into  the  streets  in  a  condition  favorable  to  contract- 
ing bronchitis  or  worse,  to  say  nothing  of  the  disagreeable  im- 
pression made  by  the  bespattered  shoes  and  odorous  disinfectant 
and  ether-impregnated  clothing. 

It  will  be  seen  that  the  attire  shown  in  the  illustration  is  held 
in  place  by  tapes.  The  operating  suit  has  to  be  relaundered  after 
each  operation,  and  if  provided  with  buttons  these  are  very  likely 
to  be  broken  or  torn  off  in  the  process  of  washing  and  ironing. 
For  this  reason  it  is  best  to  use  tapes  for  the  purpose.  The  rub- 
ber-soled shoes  are  desirable,  as  it  not  infrequently  happens  that 
irrigating  and  cleansing  solutions  flow  to  the  floor  during  opera- 
tions, and  the  surgeon  is  compelled  to  stand  in  a  messy  pool.  The 
shoes  are  worn  without  socks,  and  are  carefully  cleansed  after 
each  operation. 

The  attire  of  the  surgeon  and  assistants  should  be  completed 
outside  the  operating  room. .  In  hospital  practice  a  special  cham- 
ber is  set  aside  for  this  purpose.  The  surgeon  disrobes,  and  the 
operating  suit  is  placed  in  a  convenient  place  ready  for  wear. 

In  private  practice  a  chamber  contiguous  to  the  operating 
room  is  used  for  the  purpose,  and  the  operating  suit,  wrapped  in 
a  muslin  container,  is  removed  from  the  bag  by  the  nurse  and 
the  surgeon  puts  it  on.  The  last  visit  of  the  operator  to  the  pa- 
tient just  before  narcosis  begins  should,  however,  be  made  in 
street  costume  in  order  not  to  arouse  apprehension  which  the 
operating  suit  would  be  liable  to  cause,  were  the  surgeon  or -his 
assistants  to  present  themselves  in  a  garb  so  indicative  of  their 
work. 

The  surgeon  and  assistants,  after  attiring  themselves  in  the 
manner  stated,  are  now  ready  to  make  the  final  preparation  for 
the  surgical  manipulation. 

CLEANSING  THE  HANDS 

In  some  hospitals,  and  at  times  in  private  practice,  the  me- 
chanical cleansing,  i.e.,  the  scrubbing  of  the  hands  and  forearm, 
is  performed  in  a  chamber  contiguous  to  the  operating  room. 
The  writer  regards  the  performance  of  this  act  best  done  in  the 
operating  room.     In  private  practice  this  is  quite  impossible,  as 


CLEANSING  THE   HANDS 


127 


few,  if  any,  extemporized  operating  rooms  have  running  water 
connections.  In  hospitals  this  is,  of  course,  provided  for.  Again, 
in  some  hospitals  the  entrance  to  the  operating  room  is  provided 
with  a  swing  door  which  permits  of  access  without  contact  of  the 
hands.  However,  the  less  possibility  there  is  of  contact  with  ex- 
trinsic substances  after  the  cleansing  of  the  hands  is  begun  the 
better.  The  basin  used  should  be  roomy  and  should  permit  of 
submersion  of  the  entire  hands  and  forearms. 

For  convenience,  a  table  is  placed  beside  the  wash  basin  hold- 
ing a  glass  jar  with  sterile  brushes,  orange  sticks,  and  a  nail  file 
submerged  in  a  solution  of  carbolic  acid  1  in  100,  a  jar  of  green 
soap,  and  two  enameled  dishes,  one  containing  chlorid  of  lime 
and  the  other  sodium  carbonate  (Fig.  76).     A  large  quantity  of 


Fig.  76. — Table  with  Material  for  Cleansing  Hands.  1,  Tray  with  calcium 
chlorid;  2,  Tray  with  sodium  carbonate;  3,  Jar  containing  nail  brushes  and 
orange  sticks;    4,  Ordinary  toilet  soap;    5,  Jar  of  green  soap. 


water  and  a  liberal  amount  of  soap  should  be  employed.  The 
normal  epidermis  is  most  thoroughly  impregnated  with  bacteria, 
and  the  object  of  the  scrubbing  is  not  to  destroy  the  bacteria,  but 
to  remove  them,  and  this  can  only  be  done  by  removing  a  portion 
of  the  epidermis.  Consequently  it  is  advised  that  the  hands  be 
permitted  to  remain  in  warm  water  for  a  few  minutes  before  the 
soap  is  applied  and  thus  the  epidermis  be  macerated  and  in  a  con- 
dition favorable  to  removal.  This  manipulation  should  take 
place  in  a  roomy  wash  basin,  the  supply  cocks  of  which  are  ma- 
nipulated by  the  foot   (Fig.   77).     The  illustration  shows  a  de- 


128 


PREPARATION   OF   OPERATOR  AND   ASSISTANTS 


sirable  arrangement  in  this  regard.  The  two  upper  cocks  are  con- 
nected with  the  sterile  water  tanks  (Fig.  77),  and  are  supplied 
with  a  hand  valve  which  readily  identifies  them  from  the  lower 
outlet  connected  with  the  general  water  supply.  After  the  hands 
and  forearm  have  been  soaked  for  several  minutes  they  are  rinsed 


Fig.  77. — Wash  Stand  Used  for  Cleansing  Hands.  The  two  upper  outlets  are 
connected  with  the  sterile  water  tanks  placed  in  a  contiguous  room.  The  table 
with  the  material  necessary  for  cleansing  the  hands  is  placed  beside  the  basin. 


in  the  water  and  the  supply  in  the  basin  drained  off  and  replaced 
with  fresh  water.  The  hands  and  forearms  are  now  coated  with 
green  soap  from  the  jar  (Fig.  76),  and  the  soap  thoroughly 
rubbed  into  the  skin.  For  this  purpose  green  soap  which  has 
been  sterilized  by  heat  is  the  most  useful  agent.  It  contains  con- 
siderable free  caustic  potash  which,  together  with  the  serum  and 
exfoliated  epidermis,  makes  a  mixture  in  a  condition  favorable 
to  removal.  Haste  should  be  avoided  at  this  time  to  permit  of  a 
thorough  incorporation  of  the  soap  with  the  skin.  During  the 
time  that  the  soap  is  in  contact  with  the  skin  the  finger  nails  are 
cleansed  with  a  sharpened  orange  stick  or  nail  file.  The  former 
is  preferable  as  being  less  liable  to  injure  the  skin  contiguous  to 
the  nail. 

The  tincture  of  green  soap  and  the  ordinary  toilet  soaps  (Fig. 


CLEANSING   THE    HANDS  129 

76)  are  used  in  this  connection,  and  are  perhaps  as  effective  as 
the  green  soap,  however,  for  the  reasons  stated  the  green  soap  is 
recommended. 

This  mixture  is  now  lavaged  with  clean  water,  using  the  fin- 
gers as  in  an  ordinary  toilet.  The  water  in  the  wash  basin  is 
again  replaced,  and  with  fresh  green  soap  the  hands  and  fore- 
arms are  freely  lathered  with  the  aid  of  the  brush  taken  from 
the  glass  jar.  The  brush  should  be  used  gently  and  should 
not  be  sufficiently  harsh  to  scratch  the  skin  which  is  now  par- 
ticularly liable  to  this  accident  as  the  outcome  of  the  previous 
manipulations.  This  lather  is  then  washed  away  with  clean 
water. 

This  constitutes  the  mechanical  cleansing  of  the  hands  and  fore- 
arms, which  should  require  seven  to  ten  minutes.  It  is  the  most 
important  step  in  the  preparation.  It  is  difficult  to  see  how  chem- 
ical action  alone  can  achieve  sterility  of  the  hands,  and  indeed  it 
has  been  proven  that  it  does  not.  Indeed,  if  any  neglect  occur 
it  would  conserve  most  the  interests  of  the  patient  to  disregard 
certain  manipulations  destined  to  destroy  bacteria  by  chemical 
action  (antisepsis)  than  to  err  in  the  mechanical  cleansing.  After 
the  hands  and  forearm  have  been  treated  as  described,  they  are 
coated  with  chlorid  of  lime  made  into  a  paste  with  water,  and 
this  is  supplemented-  by  applying,  while  the  lime  is  still  on  the 
skin,  the  sodium  carbonate.  This  mixture  liberates  chlorin,  and 
is  intended  to  destroy  bacteria.  Wier  of  New  York  first  intro- 
duced this  method,  and  it  is  generally  employed. 

Care  should  be  taken  not  to  scratch  the  skin  with  rough  por- 
tions of  either  the  lime  or  soda.  The  application  gives  rise  to  a 
sensation  of  warmth  which  soon  disappears,  however.  After  the 
feeling  of  warmth  leaves,  the  mixture  is  removed  with  a  solution 
of  bichlorid  of  mercury  1  to  1,000,  using  a  piece  of  sterile  gauze 
for  the  purpose.  Care  should  be  taken  to  remove  entirely  the  lime 
and  soda,  for  if  they  be  permitted  to  remain  in  contact  with  the 
skin  for  a  protracted  period  of  time  dermatitis  is  liable  to  ensue. 
Indeed,  frequent  employment  of  the  measure  is  extremely  liable  to 
produce  dermatitis,  a  fact  which  makes  the  measure  objectionable 
if  employed  at  frequent  intervals.  It  is  the  habit  of  the  writer  to 
employ  the  measure  for  the  first  operation,  and  to  omit  this  par- 
ticular step  from  the  technic  of  cleansing  of  the  hands  and  fore- 


130  PREPARATION   OF   OPERATOR  AND   ASSISTANTS 

arms  previous  to  subsequent  operation  performed  at  the  same  sit- 
ting.   Experience  would  justify  the  omission. 

After  removing  the  lime  and  soda  in  the  corrosive  sublimate 
solution,  the  hands  and  forearms  are  immersed  in  alcohol,  this 
rinsed  off  in  a  solution  of  carbolic  acid  1  in  100,  and  finally  the 
latter  removed  with  sterile  water. 

To  facilitate  removal  of  the  lime  and  soda  mixture,  the  hands 
and  forearms  may  be  rinsed  in  a  solution  of  sodium  carbonate 
(2  per  cent.)  before  immersion  in  the  corrosive  sublimate  solu- 
tion, a  measure  which  aids  somewhat  in  obviating  the  occurrence 
of  dermatitis.      For  convenience   the   latter   three   manipulations 


Fig.  78. — Immersion  Bowls  Containing  Antiseptic  Solutions  for  Cleans- 
ing Hands  and  Forearms. 

are  performed  in  an  apparatus  shown  in  Fig.  78.  The  containers 
for  the  purpose  should  be  roomy  and  permit  of  complete  immer- 
sion of  the  parts.  The  center  one  shown  is  the  most  desirable 
form. 

This  method  of  cleansing  the  hands  is  as  effective  as  any 
known  to  the  writer.  It  is  not  claimed  that  the  hands  and  fore- 
arms are  sterile  after  its  employment.  However,  it  may  be  said 
that  absolute  sterility  of  the  hands  cannot  be  achieved  as  the 
outcome  of  even  the  most  thorough  and  painstaking  cleansing,  a 


CLEANSING   THE   HANDS  131 

fact  borne  out  by  bacteriological  examination  of  the  skin  and 
finger  nails  of  persons  who  have  subjected  them  to  the  method  of 
cleansing  generally  regarded  as  effective  for  the  purpose,  as  shown 
by  clinical  facts.  It  is  a  singular  fact  that  the  nearest  approach 
to  sterility  of  the  hands  is  obtained  after  the  operator  has  per- 
formed one  or  two  operations,  the  bacterial  flora  being  less 
marked  in  proportion  to  the  length  of  time  the  hands  have  been 
in  contact  with  aseptic  or  antiseptic  material.  This  should  argue 
that  the  perspiration  mechanically  cleanses  the  skin  and  that  ulti- 
mately the  growth  of  bacteria  in  the  skin  is  exhausted  as  the  out- 
come of  copious  dilution  of  its  culture  medium  by  material  not  fer- 
tilized. At  best  an  inhibition  of  the  growth  of  bacteria,  the  outcome 
of  the  combination  of  mechanical  cleansing  and  antiseptic  lavage 
only  is  achieved.  Yet  it  may,  too,  be  said  that  in  the  vast  ma- 
jority of  instances  this  attainment  suffices  for  practical  purposes. 
On  the  other  hand,  infection  is  in  the  opinion  of  the  writer  most 
uncommonly  the  result  of  contamination  with  instruments,  and, 
indeed,  the  appurtenances  used  in  surgical  manipulations,  and 
that  the  surgeon's  hands  and  the  conditions  which  obtain  in 
the  wound  are  the  two  elements  entering  into  the  proposition 
which  are  most  difficult  to  keep  free  from  infective  causative 
factors. 

Modification  of  the  above  method  of  preparation  is  employed, 
and  indeed  certain  variations  are  perfectly  permissible.  How- 
ever, as  far  as  the  mechanical  cleansing  is  concerned,  no  method 
yet  presented  is  more  useful  and  none  as  good.  The  lime  and 
soda  mixture  may  be  replaced  by  coating  the  hands  with  a  satu- 
rated solution  of  potassium  permanganate,  which  is  later  dis- 
placed with  oxalic  acid,  or  similar  antiseptic  preparations  may  be 
used  in  place  of  either  of  these,  but  the  rest  of  the  manipulations 
are  not  susceptible  of  modification,  and  should  be  carried  out  as 
stated. 

The  cleansing  of  the  hands  takes  place  while  the  surgeon  is 
still  attired  in  the  canvas  suit  mentioned  and  before  incasing  him- 
self in  the  sterile  apparel  in  which  the  operative  work  is  done. 
During  the  manipulations  of  getting  into  these  the  hands  are  quite 
likely  to  become  fertilized,  and  it  is  suggested  that  sterile  canton 
flannel  gloves  be  worn  at  this  time. 

11 


132 


PREPARATION   OF   OPERATOR  AND   ASSISTANTS 


CANTON  FLANNEL  GLOVES 

Canton  flannel  gloves   (Fig.   79)    are  too  cumbersome  to  be 
used  during  operations,  but  are  of  service  in  the  capacity  men- 


Fig.  79. — Canton  Flannel,  Gloves.  (Bryant.) 

tioned,  and  indeed  may  be  kept  on  until  just  before  the  operation 
is  begun,  for  it  not  infrequently  happens  that  the  operator  desires 
to  indulge  in  some  manipulation  which  might  contaminate  the 
hands,  and  if  these  be  protected  with  the  canton  flannel  gloves, 
which  are  subsequently  removed,  no  harm  will  arise  as  the  result. 


GOWNS 

The  operator  and  assistants  should  wear  sterile  gowns.  The 
gown  should  be  commodious  and  fasten  behind.  A  description  of 
the  gowns  has  already  been  given  (page  68).     In  this  connection 


GLOVES   DURING   OPERATIONS  133 

it  is  well  to  state  that  the  gown  worn  by  the  operator  and  first 
assistant  should  have  long  sleeves,  preferably  unattached  to  the 
gown,  that  they  might  be  replaced  during  the  operation  when 
soiled  by  blood  or  secretions,  and  those  of  the  other  assistants,  not 
coining  in  contact  with  the  wound,  may  be  short.  When  the  gown 
is  once  put  on  the  surgeon  must  avoid  contact  with  foreign  sub- 
stances. It  not  infrequently  happens  that  the  surgeon  is  all  ready 
to  proceed,  but  the  patient  is  not  quite  narcotized.  During  this 
time  there  is  a  tendency  on  part  of  the  operator  to  become  im- 
patient, and  it  has  been  the  writer's  experience  to  see  the  surgeon 
seat  himself  on  a  chair  with  all  the  attire  for  operation  on  and 
engage  in  conversation  with  the  assistants  or  spectators,  the  sub- 
ject of  which  is  not  infrequently  a  dissertation  on  the  stupidity 
of  the  assistant  administering  the  narcosis.  It  is  suggested  that 
the  surgeon,  who  of  necessity  is  in  a  more  or  less  tense  state  of 
mind,  do  not  put  on  the  final  sterile  attire  until  the  patient  is  on 
the  table,  in  the  meantime  protecting  the  hands  and  forearms  with 
the  canton  flannel  gloves.  This  permits  of  greater  ease  and  free- 
dom during  a  perhaps  trying  period  of  time,  allows  of  the  giving 
of  whatever  instruction  is  desired  to  spectators,  and  in  the  last 
moment  the  donning  of  the  final  attire,  which  requires  only  a  few 
moments  and  assures  the  absence  of  contamination.  The  kind  of 
gown  worn  during  operations  by  the  writer  is  shown  in  Fig.  85. 

GLOVES  DURING    OPERATIONS 

This  subject  cannot  be  dismissed  with  the  bald  statement  that 
the  interests  of  the  patient  are  best  conserved  by  the  wearing  of 
rubber  gloves  by  the  operator  and  assistants.  In  discussing  the 
subject  Kocher's  views  have  been  considered  as  having  had  a  some- 
what determining  influence  on  those  of  the  writer. 

If  the  hands  could  be  covered  with  an  impermeable  glove  which 
under  no  circumstances  permitted  of  contact  between  the  skin  of 
the  operator  and  the  wound,  the  entire  problem  would  be  solved 
except  as  regards  the  question  of  the  tactile  sense.  The  latter  is 
at  all  times  an  important  factor  in  surgical  manipulations.  The 
writer  feels  that  as  the  outcome  of  training,  the  tactile  sense  may 
be  developed,  so  as  to  be  of  sufficient  practical  acuteness  despite 
the  presence  of  the  glove,  in  the  majority  of  instances.    Yet  there 


134 


PREPARATION   OF   OPERATOR  AND   ASSISTANTS 


are  undoubtedly  instances  when  the  interests  of  the  patient  are 
best  conserved  if  the  necessary  manipulations  are  carried  on  with- 
out this  handicap. 

If  it  be  true  that  infection  is  a  question  of  dosage,  it  appears 
to  be  justifiable  that  all  assistants  wear  gloves  in  all  instances  and 
the  operator  in  most  cases,  abstaining  from  their  use,  however, 
when  the  manipulations  become  inaccurate  and  prolonged.  If  in 
these  instances  the  hands  be  cleansed  as  stated  and  frequently  sub- 
merged in  a  cleansing  solution  during  the  operation,  it  is  the 
writer's  belief  that  the  indications  are  met  on  the  most  rational 
basis. 

It  is  to  be  borne  in  mind  that  infective  bacteria  inhabit  the 


Fig.  80. — Hand  and  Wrist  Covered  with  Rubber  Glove  and  Gauntlet. 

Forearm  Bare. 


ducts  of  the  sudoriparous  and  sebaceous  glands  of  the  skin.  After 
cleansing  the  skin  these  are  not  removed.  If  the  hand  be  incased 
in  rubber  gloves  these  glands  are  stimulated  into  hypersecretion 
and  a  thin  coating  of  bacteria-incorporated  sweat  lies  in  a  layer 
between  the  skin  and  the  adove.  If  a  solution  of  continuitv  occur 
in  the  glove  as  the  outcome  of  contact  with  an  instrument,  such  as  a 
needle,  scalpel,  scissors,  or  the  wound  itself,  this  mixture  is  quite 
forcibly  projected  into  the  wound.  This  is  objectionable.  To  ob- 
viate this  it  is  perhaps  best  to  wear  cotton  gloves  for  the  first  por- 
tion of  the  operation.     These  will  absorb  the  perspiration  and  can 


GLOVES   DURING    OPERATIONS 


135 


be  frequently  changed  so  as  to  avoid  saturation,  that  is,  a  clean 
pair  is  substituted  before  the  infective  perspiration  has  permeated 


Fig.  81. — Hand  Covered  with  Rubber  Glove,  Forearm  Bandaged  with 
Sterile  Gauze,  Gauntlet  Turned  Over  Bandage. 

to  their  outer  surface.     After  a  certain  period  of  time  the  per- 
spiration dilutes  the  bacteria  to  a  sufficient  extent  to  render  the 


Fig.  82. — Forearm  Covered  by  Long  Sleeve  of  Gown,  Gauntlet  of  Rubber 
Glove  Turned  Over  Sleeve. 

skin  quite  free  from  bacteria.     It  would  seem  to  be  most  rational 
to  wear  cotton  gloves  during  the  technic  of  the  first  portion  of 


136 


PREPARATION    OF   OPERATOR   AND   ASSISTANTS 


the  operation,  that  is,  during  the  approach  to  the  area  where  more 
delicate  manipulations  are  necessary,  and  substitute  rubber  gloves 
at  this  time,  or,  if  necessary,  the  operator  may  rinse  the  hands  at 
this  time  in  a  solution  of  bichlorid  of  mercury  1  in  1,000,  which 
is  displaced  with  sterile  water  and  proceed  with  the  operation  with 
bare  hands. 

Cotton  gloves  are  less  liable  to  be  injured  during  the  manipula- 
tions involved  in  tying  ligatures  and  inserting  sutures.     The  rub- 


Fig.  83. — Ends  of  Fingers  Covered  with  Rubber  Finger  Cots. 

ber  gloves  should  be  provided  with  a  gauntlet  which  covers  the 
wrists  (Fig.  80).  Some  surgeons  prefer  to  incase  the  forearm  in 
a  sterile  gauze  bandage  (Fig.  81).  The  most  useful  method  is 
to  cover  the  entire  arm  with  the  long  sleeve  (Fig.  82).  Not  a 
few  surgeons  regard  the  ends  of  the  fingers  as  most  likely  to  be 
fertilized,  and  protect  these  with  finger  cots  (Fig.  83).  How- 
ever, this  is  not  recommended  for  prolonged  operations,  though 
exceedingly  convenient  when  the  means  for  thorough  cleansing  of 
the  hands  be  not  attainable  and  the  operation  consist  of  a  simple 
opening  of  an  abscess  or  a  cellulitis. 


CAPS   AND   MASKS 

During  operations  caps  and  masks  are  worn  by  the  operator 
and  first  assistant.     Surgeons  use  various  protectors  for  the  hair 


CAPS  AND   MASKS 


137 


and  face.  The  object 
being  to  prevent  the 
falling  of  perspiration 
and  loose  hair  into  the 
wound.  The  cap  does 
not  achieve  the  object 
as  well  as  the  mask  and 
hood  combined.  Many 
models  are  in  vogue, 
the  one  which  is  as  use- 
ful as  any  is  the  Crile 
mask,  shown  in  Fig. 
84.  It  is  effective,  light 
and     readily     put     on. 


Fig.  85. 


-Surgeon  Attired  for 
Operating. 


Fig.  84. — Crile  Mask. 

Fig.  85  shows  the  complete  attire 
of  the  surgeon  ready  for  operation. 
The  gown  is  put  on  first,  next  the 
gloves,  the  gauntlets  of  which  are 
turned  over  the  wrist,  and  the  mask 
is  put  on  by  the  non-sterile  nurse, 
as  it  would  be  quite  impossible  for 
the  surgeon  to  do  this  himself  with- 
out contamination  of  the  hands. 

The  attire  of  the  first  assistant  is 
in  all  respects  similar  to  that  of  the 
operator.  The  assistant  handling  in- 
struments and  suture  material  may 
wear  a  gown  with  short  sleeves,  a  cap 
in  place  of  a  mask,  but  should  wear 
gloves.  It  is  warned  that  if  the  latter 
test  the  tensile  strength  of  ligature 
and  suture  material  with  the  hands, 
care  be  taken  not  to  incise  the  gloves 
with  the  material. 

The  assistant  administering  the 
narcosis  need  not  indulge  in  the  elab- 
orate preparation  nor  the  attire  men- 


138 


PREPARATION   OF   OPERATOR  AND   ASSISTANTS 


tioned,  but  should  be  attired  in  freshly  laundered  duck  or  be  cov- 
ered with  a  gown.     In  the  event  of  the  operation  involving  the 
head  this  assistant  makes  the  same  preparation  as  the  operator. 
The  nurse  handling  sponges,  towels,  dressings,  etc.,  should  be 

prepared  in  the  same  way  as  the 
operator,  but  instead  of  wearing  a 
cap  ties  the  hair  up  in  sterile  gauze. 
Fig.  86  shows  the  attire  of  the  so- 
called  "  sterile  "  nurse. 

The  extra  sterile  manipulations 
are  performed  by  a  second  nurse,  who 
should  wear  the  hair  tied  in  gauze, 
be  attired  in  freshly  laundered  uni- 
form, but  need  not  wear  a  gown  simi- 
lar to  that  worn  by  the  sterile  nurse. 
The  object  of  this  is  that  during  the 
operation  the  operator  is  less  apt  to 
confuse  the  nurses,  and  not  call  upon 
the  non-sterile  nurse  to  perform  a 
duty  which  belongs  to  the  sterile 
nurse,  and  vice  versa.  This  is  a 
wise  precaution  to  take. 

The  non-sterile  nurse  replenishes 
solutions  and  pours  cleansing  fluids 
on  the  operation  field.     The  method 
of  handling  pitchers  is  already  de- 
scribed   (page  115).     The  handling 
of   basins    is    an    important   matter. 
Nurses   are   apt  to  contaminate   the 
interior  of  these  vessels  while  han- 
dling them.    Fig.  73  shows  a  commonly  employed,  erroneous  way. 
It  will  be  seen  that  the  thumbs  encroach  upon  the  inside  of  the 
bowl.     Fig.  74  shows  the  proper  way  of  handling  a  basin. 


Fig.  86. 


-Attire  of 
Nurse. 


' Sterile ' 


CHAPTEE    VII 
THE   OPERATING   ROOM 

The  hospital  operating  room:  Artificial  illumination — Operating  table — 
Dressing  table — Instrument  table — Narcotist's  table — Adjustable  tray  for 
instruments — Surgeon's  lavatory — Utensil  sterilizer — Irrigation — Arrange- 
ment of  tables,  etc.,  in  operating  room — Dressing  of  tables  in  operating 
room:  the  operating  table;  the  instrument  table;  the  anesthetist's  table; 
adjustable  instrument  tray;  dressing  table — Final  preparation  of  patient 
— Disposition  of  operator,  assistants  and  nurses. 

The  operating  room  in  private  practice:  Operating  table:  portable  operat- 
ing table;  extemporized  operating  table — Sterile  water — Suture  and 
ligature  material. 

THE   HOSPITAL   OPERATING   ROOM 

In  hospitals  and  sanitaria,  special  chambers  are  arranged  for 
the  purpose  of  performing  surgical  operations.  In  private  prac- 
tice it  is  not  possible  to  obtain  the  favorable  conditions  found  in 
these  institutions.  It  is  intended  to  describe  first  the  operating- 
room  arrangement,  which  is  most  desirable,  and  which  exists  to 
a  greater  or  lesser  degree  in  these  institutions,  and  later  take  up 
the  subject  as  applied  to  private  practice  where  modifications  of 
this  arrangement  are  necessary,  and  thus,  while  setting  up  a  stan- 
dard, show  how  this  may  be  modified  under  certain  circumstances, 
with  favorable  and  satisfactory  outcome.  In  describing  what  the 
writer  regards  as  the  most  acceptable  and  useful  arrangement,  in 
this  regard,  it  is  intended  that  a  standard  should  be  made  for  com- 
parison for  the  benefit  of  the  operator  who  works  in  private  resi- 
dences, that  the  best  might  be  as  closely  as  possible  approached, 
though  this  involve  considerable  modification  as  regards  the  ap- 
paratus employed. 

The  operating  room  should  be  at  the  top  of  the  building,  be 
large  and  readily  ventilated  and  lighted  on  three  sides  with  win- 
dows, and  be  furnished  with  a  skylight.  The  skylight  should  be 
so  situated  as  to  allow  of  light  falling  on  the  operating  table  at 

139 


140  THE  OPERATING   ROOM 

an  angle  which  will  at  the  same  time  permit  of  lateral  illumina- 
tion. That  is,  it  should  be  possible  to  have  the  light  from  the  side 
windows  fall  on  the  perineum  when  the  patient  is  in  the  lithotomy 
position  and  at  the  same  time  permit  the  patient  being  placed  in 
the  Trendelenburg  posture  without  changing  the  location  of  the 
operating  table  for  the  purpose  of  obtaining  the  necessary  light 
nor  of  turning  it  around  after  the  perineal  work  is  finished,  or 
the  reverse.  For  instance,  in  combined  vaginal  section  and  celi- 
otomy, the  former  requires  light  from  the  side  windows.  When 
the  celiotomy  is  to  be  made,  if  light  from  one  end  of  the  room  only 
is  obtainable,  it  becomes  necessary  to  turn  the  table  about  so  as  to 
have  the  light  fall  into  the  wound  during  the  intra-abdominal 
manipulations.  If  the  light  from  the  skylight  comes  in  the  oppo- 
site direction  from  the  side  windows  necessity  for  this  is  obviated. 
This  applies  with  equal  force  to  the  reverse.  If  after  a  celiotomy 
is  completed  it  becomes  expedient  to  make  vaginal  drainage,  this 
may  be  accomplished  without  moving  the  table  for  the  purpose  of 
obtaining  the  necessary  illumination.  The  skylight  should  be  per- 
manently sealed,  as  the  ropes  or  reach  rods  which  are  necessary  to 
open  and  close  windows  in  a  skylight  will,  when  manipulated  dur- 
ing an  operation,  shake  down  dust,  and  this  is  to  be  avoided.  If 
the  side  windows  are  carried  sufficiently  high  up,  efficient  venti- 
lation through  these  openings  is  at  all  times  available.  If  pos- 
sible, the  operating  room  should  derive  its  principal  source  of 
light  from  the  north. 

The  floor  of  the  operating  room  should  be  tiled,  the  tiles  set 
in  four  inches  of  cement,  and  should  have  a  smooth  surface,  to 
permit  of  cleansing  and  to  avoid  absorption  of  foreign  substances, 
including  blood,  pus  and  secretions,  which  inevitably  find  their 
way  to  the  operating-room  floor  during  surgical  manipulations. 
The  center  of  the  floor  should  be  provided  with  a  drain  and  the 
surface  of  the  floor  arranged  to  permit  of  the  flow  of  cleansing 
fluids  to  this  point.  Various  mixtures  of  cement  and  plaster 
have  been  used  to  make  solid  flooring,  none  of  which  are,  how- 
ever, as  permanently  lasting  as  the  tiling. 

The  junction  of  the  floor  and  walls  should  be  provided  with  a 
curved  tile  which  permits  of  ready  cleansing  and  avoids,  too,  col- 
lection of  dust  and  foreign  particles  in  this  situation.  The  walls 
should  be  tiled  to  the  height  of  six  feet  and  the  upper  portions 


THE   HOSPITAL   OPERATING   ROOM  141 

made  of  cement  painted  with  four  or  five  coats  of  enameled  paint. 
The  junction  of  wall  and  ceiling  should  be  arched  rather  than 
make  an  acute  angle  to  avoid  collections  of  foreign  substances  in 
this  situation.  The  entire  interior  of  the  room  should  be  white, 
to  facilitate  the  detection  of  objectionable  material  and  enhance 
illumination. 

ARTIFICIAL  ILLUMINATION 

Artificial  illumination  should  be  by  electricity,  and  the  cur- 
rent governed  from  a  side-wall  switch  to  avoid  shaking  down  of 
dust,  the  outcome  of  manipulations  at  the  chandelier.  The  chan- 
delier should  be  furnished  with  a  reflector  and  the  electric  light 
bulbs  grouped  in  a  cluster  to  avoid  the  throwing  of  confusing 
shadows  on  the  operation  field.  The  source  of  light  should  be  suf- 
ficiently high  over  the  table  to  avoid  contact  with  the  operator 
during  manipulations  such  as  suturing  with  a  long  suture  during 
celiotomy  in  the  Trendelenburg  posture. 

The  section  of  wiring  conveying  the  electric  current  to  the 
operating  room  should  be  heavily  fused  and  the  wires  themselves 
made  of  ample  capacity  to  carry  a  current  of  sufficient  strength, 
to  be  available  for  the  animation  of  motors  for  the  purpose  of  run- 
ning burrs  and  drills,  and  also  for  the  purpose  of  heating  a  cautery 
knife.  It  is  an  annoyance,  to  say  the  least,  to  have  the  steps  of 
an  operation  interrupted  as  the  result  of  a  fuse  "  burning  out " 
while  the  operator  is  manipulating  in  the  opened  abdomen,  and 
thus  be  compelled  to  delay  the  procedure  until  the  necessary  re- 
pair is  made,  simple  as  this  is. 

When  electric  light  is  not  available,  the  chandelier  in  the  oper- 
ating room  should  be  so  located  as  to  make  it  possible  to  carry  on 
the  operation  at  some  place  other  than  immediately  beneath  it, 
and  when  it  becomes  necessary  to  use  the  artificial  light  the  table 
may  be  moved  to  immediately  beneath  it. 

Of  course,  in  instances  when  operations  are  performed  at  night, 
the  gas  jets  are  ignited  before  the  operation  is  begun  and  no  manip- 
ulations in  this  connection  are  necessary  during  the  operation. 
However,  it  not  infrequently  happens  that  the  operation  is  begun 
with  ample  available  daylight  and  the  contingencies  of  the  sur- 
gical problem  make  continuance  of  the  effort  a  prolonged  one,  so 
that  darkness  occurs  before  the  operation  is  finished.     Indeed,  a 


142  THE   OPERATING   ROOM 

thunderstorm  will  frequently  obliterate  the  daylight  at  midday, 
and  it  becomes  necessary  to  employ  artificial  light  in  the  midst  of 
an  operation.  Under  these  circumstances,  it  is  of  course  not  feas- 
ible to  ignite  the  gas  "without  manipulating  the  chandelier,  and 
dust  is  shaken  down  on  the  operating  field  unless  the  precaution 
mentioned  is  taken. 

If,  however,  the  gas  chandelier  be  located  immediately  over 
the  operating  table,  the  wound  and  contiguous  area  should  be  cov- 
ered with  a  sterile  sheet  while  the  gas  is  lighted  by  the  non-sterile 
nurse,  and  later  the  same  person  removes  the  sheet,  together  with 
the  dust,  after  which  the  operation  is  proceeded  with. 

The  apparatus  necessary  to  the  sterilization  of  water  and  dress- 
ings (Fig.  66)  should  be  set  up  in  a  chamber  contiguous  to  the 
operating  room.  The  water  sterilizers,  however,  should  be  piped 
into  the  operating  room,  that  the  supply  in  use  may  be  replen- 
ished without  the  attendant  being  forced  to  leave  the  room.  The 
dressings,  sponges,  etc.,  are  packed  in  convenient  parcels  which 
can  be  transported  to  the  scene  of  operation  without  danger  of 
contamination. 

The  instrument  (Fig.  16)  and  utensil  sterilizers  (Fig.  96) 
should,  however,  be  in  the  operating  room,  as  conditions  con- 
stantly arise  making  immediate  resterilization  of  this  appliance 
necessary.  An  instrument  is  dropped  to  the  floor  or  is  fertilized 
by  contact  with  infectious  material  quite  frequently  during  an 
operation,  and  means  for  rapid  sterilization  should  be  at  hand. 
The  same  may  be  said  of  pans  and  basins  and  pitchers,  and  when 
these  are  at  once  placed  in  the  sterilizers  they  become  available  for 
use  after  a  short  period  of  time,  a  desirable  provision  which  tends 
to  obviate  delay  and  annoyance  during  the  operation. 

OPERATING   TABLE 

The  table  shown  here  (Figs.  87-90)  is  as  serviceable  as  any  in 
the  market,  and  provides  for  the  requisites  of  most  contingencies 
arising  during  operative  work.  There  are  many  tables  on  the 
market  which  will  serve  the  purpose,  indeed  in  some  instances  the 
surgeon  does  more  satisfactory  work  as  the  outcome  of  familiarity 
with  a  table  which  may  be  less  complete  in  every  jDarticular  than 
obtains  in  the  table  shown  here,  but  it  may  also  be  said  that  this 
particular  table  may  be  regarded  as  a  standard  which  if  it  have 


THE   HOSPITAL   OPERATING   ROOM 


143 


any  fault  is  too  elaborate,  and  that  on  general  principles  the  cen- 
tralization of  too  many  possibilities  is  liable  to  mean  mechanical 
complications. 

It  is,  for  instance,  perfectly  feasible  to  attain  the  Moynihan 
position  for  easier  access  to  the  bile  passages  by  placing  a  sand 


Fig.  87.- 


-Operating  Table  Showing  Appliance  for  Raising  the  Upper 
Abdomen  or  for  Use  in  the  "Kidney"  Position. 


bag  under  the  patient,  yet  the  Cunningham  adjustable  elevating 
attachment  is  certainly  more  readily  adjusted  to  varying  condi- 
tions than  the  former.  The  table  here  shown  is  the  result  of  the 
ingenuity  of  Dr.  Francis  Marh oe  of  New  York  City.  The  table 
frame  is  of  tubular  iron ;  the  drainage  pan  attached  to  the  base  is 
wider  than  the  top  of  the  table,  assuring  drainage  on  the  sides 
when  lavage  is  made,  preventing  the  solution  from  running  on 
the  floor  or  soaking  into  the  lower  garments  of  the  surgeon  and  his 
assistants.  The  base  is  designed  to  permit  of  the  tops  being  low- 
ered, the  plane  at  the  foot  end  facilitating  the  Hartley  position. 
The  foot  end  is  adjustable  to  any  angle;  it  is  also  arranged  to 


144 


THE   OPERATING  ROOM 


drop  back,  permitting  the  use  of  weighted  specula  in  the  lithotomy 
position.  Close  scrutiny  of  the  cut  (Fig.  88)  will  show  that  the 
foot-piece  not  only  drops  down  at  an  angle  of  90°,  but  also  slips 
backward,  allowing  an  overhanging  of  the  end  of  the  center  sec- 


Fig.  88. — Operating  Table  Showing  Appliances  for  Lithotomy  Positions 
and  Wire  for  Screening  off  Narcotist. 


tion  to  permit  of  the  manipulation  stated.  This  prevents  the  as- 
sistant's hand,  while  holding  a  speculum,  from  getting  in  the  way. 

The  Trendelenburg  posture  is  achieved  by  means  of  the  Dela- 
tour  side-wheel  attachment  with  rack  and  pinion,  which  is  con- 
trolled by  the  narcotist,  thus  obviating  disturbance  of  the  celiotomy 
sheet  during  changes  of  posture.  A  foot  pedal  at  the  end  of  the 
table  near  the  head  section  allows  of  raising  of  this  section  by  the 
narcotist  as  occasion  arises. 

The  Cunningham  elevating  attachment  is  adjustable,  and  is 
either  used  with  the  side  braces  to  maintain  the  kidney  position 
or  without  these  braces  for  the  Moynihan  position  for  work  on  the 
biliary  passages.     The  Lange  table  is  attached  when  necessary  to 


THE   HOSPITAL   OPERATING   ROOM 


145 


the  foot  section  and  serves  as  a  foot  rest  in  the  Hartley  position. 
The  wire  screen  shown  in  Figs.  87-90  holds  the  celiotomy  sheet 
away  from  the  narcotist  and  isolates  the  head  of  the  patient  from 
the  rest  of  the  table,  a  desirable  arrangement  in  instances  in  which 
local  or  spinal  anesthesia  is  employed.  The  patient  is  thus  un- 
able to  see  the  manipulations,  a  factor  which  has  a  bearing  on  the 
mental  shock,  so  often  the  sequel  of  operations  undertaken  with 
local  anesthesia.  Beyond  this  the  table  is  furnished  with  shoulder 
supporters  to  prevent  the  patient  from  sliding  upward  when  in 
the  Trendelenburg  position  and  lithotomy  stirrups.  Fig.  87  shows 
the  table  with  screen  frame  and  Cunningham  elevating  attachment. 
Fig.  88  shows  the  foot  rest,  the  foot  section  dropped  and  a  heel 
cup  and  lithotomy  stirrup  attached.     Fig.  89  shows  the  table  in 


Fig.  89. — Operating  Table  Arranged  for  Hartley's  Position. 


the  Hartley  position  with  the  foot  rest  attached  to  prevent  slipping 
of  the  patient.  In  neither  of  these  illustrations  are  the  shoulder 
supports  shown,  which  are  of  course  only  attached  when  the  Tren- 
delenburg posture  is  to  be  employed.  Fig.  90  shows  the  table  in 
the  Trendelenburg  position  with  shoulder  supports  attached,  though 
the  head  section  should  perhaps  be  best  slightly  raised  to  show 


146 


THE   OPERATING   ROOM 


the  most  generally  employed  Trendelenburg  position.     If  the  foot 
section  is  dropped  when  the  patient  is  to  be  placed  in  the  Tren- 


Fig.  90. — Operating  Table  in  Trendelenburg's  Position. 

delenburg  posture,  the  weight  of  the  legs  prevents  undue  pressure 
on  the  shoulders  from  contact  with  the  supporters,  though  it  also 
makes  tense  the  abdominal  muscles. 


DRESSING  TABLE 

A  table  for  dressings,  wipes,  towels,  etc.,  should  be  available. 
Tig.  91  shows  a  steel  white  enameled  table  frame  with  two  glass 
shelves.  The  dimensions  of  this  table  are  about  24  by  36  inches, 
of  ample  size  to  hold  sufficient  material  for  an  ordinary  operation, 
and  is  not  so  large  as  to  be  unwieldy.  If  an  extensive  operation  or 
two  or  more  operations  are  to  be  performed  successively,  two  of 
these  tables  may  be  arranged  contiguous  to  each  other. 


Fig.  91. — Table  for  Dressings 


Fig.  92. — Table  for  Instruments. 


12 


147 


148 


THE   OPERATING   ROOM 


INSTRUMENT  TABLE 

Fig.  92  shows  a  roomy  steel  frame  table  with,  two  glass  shelves 
suitable  for  instruments  during  the  operation.  This  table  should 
be  the  same  size  as  shown  as  a  dressing  table  (Fig.  91).  Of  course 
either  table  may  be  used  for  either  of  the  purposes  mentioned. 

A  table  as  shown  in  Fig.  91  may  be  used  for  suture  material 
containers,  jars  of  catgut  (Fig.  49),  needles,  etc.  The  instru- 
ment and  suture  material  tables  should  stand  beside  each  other  as 
both  these  classes  of  surgical  desiderata  are  usually  handled  simul- 
taneously. 

NARCOTIST'S  TABLE 

The  table  shown  in  Fig.  93  is  used  by  the  narcotist,  to  hold 
the  receptacles  containing  the  narcotic,  stimulants,  a  hypodermic 
syringe,  etc.    The  table  is  of  steel,  white  enameled,  as  are  the  other 

tables,  and  has  a 
glass  shelf.  The 
lower  shelf  is  of  en- 
ameled steel  and 
holds  the  pus  basin 
used  to  receive  the 
vomit  during  or  im- 
mediately after  the 
operation.  The  rack 
below  the  lower  shelf 
is  intended  for  tow- 
els which  may  be 
used  to  wipe  the  pa- 
tient's face  or  lips 
during  the  opera- 
tion. 

ADJUSTABLE    TRAY 
FOR  INSTRUMENTS 

During  an  opera- 
tion a  certain  num- 
ber of  instruments 
are  more  or  less  con- 

FlG.  93.— Narcotist's  Table.  stantly    in    USC        To 


THE   HOSPITAL   OPERATING   ROOM 


149 


facilitate  the  work  an  adjustable 
table  frame  with  an  enamel  tray 
(Fig.  94)  is  placed  close  to  the 
surgeon,  and  the  assistant  han- 
dling the  instruments  places  the 
instruments  for  immedate  use 
upon  it.  The  table  is  usually 
placed  to  extend  over  the  operat- 
ing table.  By  means  of  the  set 
screw  the  tray  is  raised  or  lowered 
by  the  telescoping  of  the  upright 
to  meet  the  necessities. 

When  an  instrument  is  tem- 
porarily laid  aside  it  may  be 
placed  upon  this  tray,  rather  than 
upon  the  area  contiguous  to  the 
wound.  The  latter  is  usually 
soiled  with  blood   and  secretions, 

which  makes  it  an  objectionable  place  to  lay  instruments  upon. 
Again,  if  during  the  operation  the  patient  should  struggle  the  in- 
struments are  less  liable  to  be  thrown  to  the  floor,  if  placed  upon 
the  tray,  than  if  the  body  of  the  patient  be  used  for  the  purpose. 


Fig.  94. 


Adjustable  Instrument 
Tray. 


Fig.  95. — Surgeon's  Lavatory. 


SURGEON'S  LAVATORY 

The  surgeon's  lavatory 
should  be,  as  already  stated 
(page  127),  sufficiently 
roomy  to  permit  of  the  sub- 
mersion of  the  hand  and 
forearm.  The  basin  shown 
in  Fig.  95  is  fitted  with  a 
knee  lever  attachment  allow- 
ing of  the  delivery  of  either 
cold  or  hot  water.  The  knee 
lever  at  the  left  side  in  the 
center  opens  or  shuts  the 
waste.  The  material  neces- 
sary to  cleansing  the  hands 
is  placed  on  the  glass  shelf 


150 


THE   OPERATING   ROOM 


immediately  above  the  wash  basin  and  is  thus  readily  available. 
The  toilet  soap  is  placed  in  the  small  soap  tray  affixed  to  the  wall 


Fig.  96. — Operating  Room  Utensil  Sterilizer. 

beneath  the  shelf.  The  water  outlet  is  arranged  in  a  "  goose- 
neck "  which  permits  of  lavage  of  the  hands  and  forearm  with 
running  water. 

This  apparatus  is  very  convenient  and  quite  useful  for  the 


THE   HOSPITAL   OPERATING   ROOM 


151 


purpose.  It  is  well  to  bear  in  mind,  however,  that  it  represents 
a  refinement  which,  while  acceptable,  is  in  no  wise  essential  to 
cleansing  of  the  hands.  The  ordinary,  roomy  wash  basin  will  suf- 
fice very  well  for  the  purpose,  and  indeed  has  the  redeeming 
feature  of  being  less  complicated  in  its  mechanism. 


UTENSIL   STERILIZER 

The  utensil  sterilizer  (Fig.  96)  should  be,  as  already  stated, 
located  in  the  operating  room.  It  is  fitted  with  a  foot  pedal,  by 
means  of  which  the  cover  may  be  raised  and  the  tray  elevated 
without  the  need  of  using  the  hands. 

The  appliance  is  used  for  the  purpose  of  sterilizing  pitchers, 
basins,  irrigating  vessels  and  the  like.  It  is  fitted  with  either  the 
direct  Bunsen  burner  flame  or  is 
connected  with  the  steam  pressure  of 
the  power  plant  in  the  building.  The 
former  method  of  heating  is  prefer- 
able. The  contents  should  be  ex- 
posed to  a  temperature  of  212°  F. 
for  half  an  hour,  which  will  com- 
pletely sterilize  it. 

IRRIGATION 

For  the  purpose  of  lavage  dur- 
ing the  operative  procedure,  besides 
the  pitchers  already  mentioned  (page 
115),  it  is  well  to  have  at  the  dis- 
position of  the  surgeon  an  irrigator, 
especially  as  the  latter  may  be  used 
for  infusions,  enteroclysis,  and  hypo- 
dermoclysis.  A  useful  apparatus  for 
the  purpose  is  shown  in  Fig.  97.  A 
glass  receptacle  of  a  gallon  capacity 
is  swung  from  the  hook  at  the  top 
of  an  upright.  The  receptacle  is 
connected  at  the  bottom  with  a  rubber 
tube.  A  thermometer  (Fig.  42)  is 
prevent  the  contamination  with  the 


Fig.  97. — Operating   Room    Ir- 
rigating Apparatus. 

placed  in  the  retort,  and  to 
infective  material  a  sterile 


152 


THE   OPERATING   ROOM 


towel  is  made  to  cover  the  open  top.  The  rubber  tube  is  led  into 
a  basin  affixed  to  the  stand  containing  a  solution  of  mercury  bi- 
chlorid,  1  in  1,000.  The  tube  is  shut  off  by  means  of  a  forceps, 
which  is  released  when  it  is  desired  to  have  the  solution  flow,  the 
various  "  cut-off  "  appliances  in  the  market  rarely  being  efficient 
for  a  sufficient  period  of  time  to  render  their  employment  desirable. 


Dressings. 


Table  for  Basins,  &o. 


Nurse.  £) 


(3  Burse 


Chief  Assistant. 

o 


ARRANGEMENT   OF  TABLES,   ETC.,   IN   OPERATING   ROOM 

Fig.  98  is  a  diagrammatic  presentation  of  a  convenient  method 
of  arranging  the  tables  in  the  operating  room,  and  also  the  ar- 
rangement of  the  assist- 
ants to  serve  best  the  con- 
tingencies. Fig.  99  shows 
the  tables,  irrigator,  wash 
basin,  and  instrument  case 
as  arranged  in  a  well- 
equipped  operating  room. 
Of  necessity  modifications 
of  arrangement  to  suit  the 
available  space  is  permis- 
sible. For  instance,  the 
instrument  case  is,  in 
many  institutions,  placed 
in  an  adjoining  room; 
however,  if  the  operating 
room  is  sufficiently  large, 
it  had  best  be  kept  there, 
with  the  view  of  obtaining 
without  delay  instruments 
which  have  either  been  for- 
gotten by  the  assistant  or 
which  may  be  called  for  to 
meet  an  unforeseen  contingency.  The  delay  of  sending  out  of 
the  room  a  nurse  during  the  operation  for  the  purpose  of  obtain- 
ing an  instrument  or  appliance  is  objectionable. 


o 

Second  Assistant. 


Spare  Instruments. 


Fig.  98. — Diagram  of  Arrangement  of 
Apparatus  and  Assistants  During  a 
Celiotomy  Operation.       (Bryant.) 


THE   HOSPITAL   OPERATING   ROOM 


153 


DRESSING   OF    TABLES   IN   OPERATING   ROOM 

The  Operating  Table. — The  glass  surface  of  the  operating  table 
presents  a  hard  surface  for  the  patient  to  lie  on.     While  it  would 


Fig.  99. — Tables,  Etc.,  Used  in  Operating  Room. 

conserve  perhaps  best  both  cleanliness  and  drainage  to  place  the 
patient  immediately  upon  the  glass  surface  of  the  table,  it  has 


Fig.  100. — Operating  Table  Covered  with  Pads. 

been  found  that  the  subsequent  discomfort  to  the  patient,  the  out- 
come of  prolonged  contact  with  a  hard  surface,  is  exceedingly  ob- 
jectionable,    To  obviate  this,  the  table  is  covered  with  two  pads 


154  THE   OPERATING   ROOM 

composed  of  cotton  which  are  incased  in  rubber  sheeting  and  then 
covered  with  a  linen  case  to  fit  the  pad.  These  are  fastened  to 
the  operating  table  with  tapes  (Fig.  100),  an  arrangement  which 
does  not  interfere  with  drainage,  and  the  linen  cases  are  removed 
and  replaced  with  fresh  ones  after  each  operation,  conserving 
cleanliness. 

The  Instrument  Table. — The  instrument  table  is  covered  with 
a  sterile  towel    (Fig.    101)   or  sheet,  and  the  instruments  after 


Fig.  101. — Instrument  Table  Covered  with  Sterile  Towel. 

being  taken  from  the  sterilizer  are  placed  upon  it.  Fig.  102 
shows  a  serviceable  arrangement  in  this  connection.  In  this  in- 
stance two  tables  are  placed  contiguous  to  each  other  and  covered 
with  a  sterile  sheet.  Upon  the  sheet  sterile  towels  are  placed, 
which  may  be  replaced  when  this  set  becomes  soiled.  A  pan  of 
sterile  water  of  moderate  temperature  is  placed  beside  the  in- 
struments for  two  purposes :  first,  the  instruments  as  they  come 
from  the  sterilizer  are  very  hot  and  cannot  be  handled.  If  they 
be  submerged  for  a  few  minutes  in  cool  sterile  water  this  is  ob- 
viated ;  and,  second,  during  operations,  the  instruments  become 
soiled  and  may  be  cleansed  in  the  sterile  water,  thus  permitting 
of  easier  manipulation  than  obtains  when  instruments  are  slip- 
pery from  a  coating  of  blood  or  secretions.  Fig.  103  shows  the 
pan  with  a  portion  of  the  instruments  submerged  for  the  purpose 
mentioned. 

The  Anesthetist's  Table. — The  anesthetist's  table  need  not  be 
protected  by  sterile  material  unless  the  operation  involves  the 
head   and  face.     Fig.    104   shows  the   arrangement   universally 


Fig.  102. — Instruments  Spread  on  Sterile  Towel,  Ready  for  Use. 


Fig.  103. — Instruments  Ready  for  Use,  a  Portion  of  Which  are  Suh- 
merged  in  Sterile  Water. 


155 


156 


THE   OPERATING   ROOM 


found  useful.  The  modified  Esmarch  mask  is  used  in  the  writ- 
er's cases  -for  the  administration  of  ether  by  the  so-called  open 
method,  and  if  for  any  reason  chloroform  is  to  be  used,  it  may  be 
dropped  on  the  same  apparatus. 

The  chloroform  and  ether  bottles  and  bottles  containing  stimu- 
lants are  placed  together.  The  pus  basin  is  used  for  receiving  the 
vomit,  and  the  hypodermic  syringe  is  placed  in  a  glass  receptacle 
submerged  in  carbolic  acid  solution  (1-40).     Besides  this  a  grad- 


Fig.  104. — Table  Arranged  with  Material  Necessary  to  Narcotist. 


uate  and  a  glass  containing  small  squares  of  gauze  are  kept  oil 
hand,  the  latter  being  employed  to  moisten  the  patient's  lips  or 
wipe  out  the  pharynx.  For  the  latter  purpose  a  sponge  holder, 
shown  in  the  illustration,  is  employed.  Besides  this  a  Whitehead 
mouth  gag,  a  tongue  depressor,  and  scissors  should  be  placed  ready 
for  use.  The  two  towels  are  intended  to  be  used  as  necessity 
arises,  though  the  gauze  seen  in  the  pus  basin  will  serve  all  pur- 
poses for  which  towels  are  ordinarily  employed.  However,  the 
greater  absorbing  capabilities  of  the  gauze  recommends  its  use 
in  preference  to  the  towel,  though  the  latter  may  become  of  ser- 
vice in  the  event  of  profuse  vomiting. 

The  Adjustable  Instrument  Tray. — The  adjustable  tray  is  first 
covered  with  a  sterile  pillow  slip,  which  is  tucked  about  the  stand 


THE   HOSPITAL   OPERATING   ROOM  157 

(Fig.  105).     Upon  this  a  sterile  towel  is  placed,  and  the  instru- 
ments in  immediate  use  are  laid  upon  this   (Fig.   106).     From 


Fig.  105. — Adjustable  Instrument  Tray  Covered  with  Sterile  Pillow- 
case Tucked  About  Stand. 

time  to  time  the  assistant  in  charge  of  the  instruments  replaces 
various  tools  with  duplicates  and  cleanses  the  former,   holding 


Fig.  106. — Adjustable  Instrument  Tray  with  Sterile  Towel  and  Instru- 
ments in  Immediate  Use. 


158  THE   OPERATING   ROOM 

them  ready,  upon  the  larger  table  (Fig.  102),  to  take  the  place 
of  the  set  in  use  when  occasion  arises.  From  time  to  time  the 
nurse  changes  the  sterile  towel  without  disturbing  the  sterile 
pillow  case. 

Dressing  Table. — The  table  for  dressings,  wipes,  etc.,  is  in- 


Fig.  107. — Dressing  Table  Arranged  for  Extensive  Operation  or  when  Sev- 
eral Major  Operations  are  to  be  Performed  in  Immediate  Sequence. 


tended  to  hold  material  handled  by  the  sterile  nurse.  Fig.  107 
shows  a  table  dressed  for  an  extensive  operation  or  for  several 
operations  to  be  performed  in  rapid  succession.  The  jars  con- 
tain medicated  gauze,  sterile  absorbent  cotton,  and  sterile  gauze 
bandages.  The  packets  contain  sterile  gauze,  wipes,  and  ab- 
dominal pads.     Beside  this,  the  table  holds  sponge  holders,  two 


THE   HOSPITAL   OPERATING   ROOM 


159 


glasses  for  emergency,  and  a  basin  with  sterile  water  for  the  pur- 
pose of  rinsing  soiled  sponge  holders. 

This  is  the  arrangement  which  the  writer  employs.  However, 
immediately  after  the  various  materials  have  been  disposed  upon 
the  table,  they  are  covered  with  a  sterile  sheet  (Fig.  108),  and 
when  anything  is  to  be  used  the  nurse  lifts  the  edge  of  the  sheet 
and  obtains  it.     This  lessens  the  chances  of  accidental  contamina- 


Fig.  108. — Dressings,  Etc.,  Protected  by  Sterile  Sheets. 


tion  from  dust  or  other  sources,  such  as  sputtering  of  cleansing 
solutions  which  have  been  forcibly  projected  against  the  wound 
area.  The  jars,  of  course,  need  not  be  covered,  as  they  are  opened 
only  when  a  portion  of  the  contents  is  removed  and  the  covers 
are  immediately  replaced. 

Fig.  109  shows  a  table  which  is  arranged  for  operations  in 
small  sanitaria,  where  a  single  assistant  handles  towels,  dressings, 


160 


THE   OPERATING   ROOM 


instruments,  and  solutions.  The  table  is  fitted  with  a  frame  over 
which  sterile  towels  are  laid.  The  latter  are  usually  submerged 
in  sublimate  solution  after  being  boiled  with  the  view  of  prevent- 
ing contamination  from  surroundings.  The  tray  holding  towels 
and  dressings  are  of  agate-covered  metal,  and  while  not  as  clean- 
looking  as  the  white  enameled  ones  holding  instruments,  are  just 
as  useful  for  the  purpose.     The  spirit  flame  is  intended  for  the 


Fig.  109. — Table  Arranged  with  Instruments  and  Dressings  Suitable 
for  Small  Sanatoria. 

heating  of  instruments  which  may  have  become  accidentally  con- 
taminated. The  writer  has  found  this  arrangement  exceedingly 
satisfactory,  especially  when  the  number  of  assistants  is  small. 
The  larger  glass  jar  contains  rubber  gloves,  and  the  glass  carafe 
solution  prepared  in  the  manner  shown  in  Figs.  138  and  139. 


FINAL  PREPARATION   OF  PATIENT 


The  preparations  just  related  take  place  while  the  patient  is 
still  in  the  contiguous  chamber  being  narcotized.  The  description 
following  is  based  on  the  steps  taken  when  celiotomy  is  made,  but  is 
equally  applicable  to  operations  on  other  portions  of  the  body.     In 


THE   HOSPITAL   OPERATING   ROOM 


161 


hospitals  and  institutions  the  patient  after  being  properly  attired 
(Fig.  15)  is  placed  on  a  carriage  upon  which  he  is  finally  trans- 


Fig.  110. — Carriage  for  Transportation  of  Patient  to  Operating  Room, 
Covered  with  Pad. 


ported  to  the  operating  room.     This  carriage  is  of  enameled  steel, 
the  top  of  which  is  padded  with  a  folded  blanket  enveloped  in  a 


Fig.  111. — Carriage  Covered  with  Blanket  and  Small  Pillow. 


sheet  (Fig.  110).  A  blanket  is  draped  over  this,  and  a  flat  pillow 
placed  at  one  end  for  the  patient's  head  (Fig.  111).  Upon  this 
a  sheet,  folded  into  a  square,  is  placed  so  as  to  correspond  to  the 


162  THE  OPERATING  ROOM 

thorax  and  abdomen  of  the  patient  (Fig.  112).     This  is  used  to  lift 
the  patient  from  the  carriage  to  the  operating  table. 


Fig.  112. — Carriage  with  Folded  Sheet  over  Blanket. 

Fig.  113  shows  the  patient  as  he  lies  on  the  folded  sheet  and 
blanket.  A  large  sheet  is  now  tucked  about  the  patient  in  the 
manner  shown  in  Fig.  114,  which  is  of  assistance  in  controlling 


Fig.  113. — Patient  Placed  on  Carriage. 

the  struggling  which  occurs  quite  often  at  the  beginning  of  nar- 
cosis. 

The  sheet  and  blanket  are  now  folded  over  the  body,  and  a  sec- 


THE   HOSPITAL   OPERATING   ROOM  163 

ond  short  blanket  is  thrown  across  the  thorax,  as  shown  in  Fig.  115. 
When  the  patient  is  narcotized  he  is  wheeled  into  the  operating 


Fig.  114. — Restraining  Sheet  Placed  about  Patient. 

room,  the  blankets  and  sheet  are  unfolded,  and  he  is  lifted  with  the 
aid  of  the  short  sheet  (Fig.  112)  to  the  operating  table.  The  part 
to  be  operated  upon  is  now  exposed,  and  the  contiguous  portions 


Fig.  115. — Patient  Completely  Prepared  for  Narcosis  and  Subsequent 
Transportation  to  Operating  Room. 
13 


164 


THE   OPERATING   ROOM 


of  the  body  covered  with  folded  blankets  (Fig.  116),  which  are 
covered  with  rubber  sheets  (Fig.  117)  to  protect  the  latter  from 
moisture. 

The  assistant  now  proceeds  to  give  the  part  the  final  prepara- 
tion.    For  this  purpose  the  nurse  has  prepared  a  bottle  of  sterile 


Fig.   116. — Surrounding  Parts  of  Operative  Field  Covered  with 
Woolen  Blankets. 

tincture  of  green  soap,  a  mixture  of  alcohol  and  ether,  a  flask  of 
solution  of  bichlorid  of  mercury  1  in  1,000,  and  another  con- 
taining sterile  water.  These  are  conveniently  arranged  on  a  tray 
or  table  (Fig.  118).  The  flasks  are  both  stoppered  with  cotton, 
and  the  one  containing  the  mercury  solution  has  a  small  label  af- 
fixed for  purposes  of  identification,  though  it  would  be  best  to 
have  the  mercury  solution  colored  blue. 

The  assistant,  who  wears  gloves  and  has  not  yet  donned  his 


THE   HOSPITAL  OPERATING   ROOM 


165 


sterile  gown,  gently  scrubs  the  skin  with  tincture  of  green  soap 
and  sterile  water  poured  on  the  skin  by  the  non-sterile  nurse. 
This  is  displaced  with  sterile  water  from  the  flask,  and  the  solu- 
tion of  alcohol  and  ether  poured  over  the  surface.  The  object  of 
this  application  is  to  dissolve  the  grease  from  the  sebaceous  glands 


Fig.   117. — Woolen  Blankets  Protected  from  Moisture  avith 
Rubber   Sheets. 

not  removed  by  the  scrubbing.  The  ether  and  alcohol  are  removed 
with  a  copious  quantity  of  water  poured  from  a  pitcher,  as  shown 
in  Fig.  71.  The  temperature  of  the  water  used  for  this  purpose 
should  be  about  80°  F.,  in  order  to  prevent  burning  of  the  skin 
on  the  dependent  portions  of  the  body. 

The  non-sterile  nurse  now  lavages  the  part  with  the  bichlorid 
solution,  and  this  is  finally  displaced  with  a  large  quantity  of 
sterile  water. 


166  THE   OPERATING   ROOM 

A  useful  method  of  sterilizing  the  skin  preliminary  to  opera- 
tions under  local  anesthesia  is  employed  by  Grossich.  A  ten  or 
twelve  per  cent,  iodin  tincture  is  applied  to  the  field  of  opera- 
tion and  surrounding  skin,  with  a  brush,  without  any  preliminary 
scrubbing.  The  microscope  has  shown  that  the  tissues  take  up  the 
iodin  much  more  readily  when  dry,  and  that  it  penetrates  deeply 
into  all  the  nooks  and  crevices,  which  does  not  occur  with  the  usual 
preliminary  scrubbing  with  soap  and  water.     The  water  macerates 


^^^^ta—^oWKiM^^^H 

mrnim     i1 

MM    '  Hi 

Or  fl 
l                               II 

1      m 

/  •    ml 

( 

POISON     1 

wu~P 

•■■"-aBBBBl 

Fig.  118. — Convenient  Arrangement  of  Articles  Necessary  to  Final 
Cleansing  of  Skin  with  Patient  on  Operating  Table. 

the  epidermal  cells,  causing  them  to  plug  the  openings.  The  parts 
are  shaved,  dried  and  then  painted  with  the  iodin.  After  anes- 
thesia is  produced,  the  field  of  operation  is  again  painted  with  tinc- 
ture of  iodin,  and  finally  the  completed  suture  is  again  swabbed 
with  it.  Grossich  states  that  if  the  iodin  is  applied  after  the  parts 
have  been  recently  scrubbed  with  soap  and  water,  there  is  liable 
to  be  suppuration.  It  is  indispensable  that  the  tissues  should  be 
dry  when  the  iodin  is  applied. 

The  assistant  removes  the  rubber  gloves,  rinses  his  hands  in 
sterile  water,  puts  on  the  gown,  incases  the  hands  in  fresh  gloves 
and  has  the  nurse  put  the  mask  in  place. 


THE   HOSPITAL  OPERATING   ROOM 


167 


The  rubber  sheets  are  covered  at  the  ends  nearest  the  operation 
field  with  sterile  towels  (Fig.  119),  and  the  patient  covered  with 
the  celiotomy  sheet,  which  is  provided  with  an  oblong  opening  to 
correspond  to  the  part  to  be  operated  upon  (Fig.  120).  It  is  neces- 
sary that  the  sheet  be  of  sufficient  dimensions  to  drape  well  down 


Fig.  119. — Rubber  Sheets  Covered  with  Sterile  Towels. 


over  the  sides  of  the  operating  table  (Fig.  121).  The  field  of 
operation  is  protected  additionally  by  four  sterile  towels  fastened 
together  in  the  manner  shown  in  Fig.  122,  which  are  placed  in 
situ  as  shown  in  Fig.  123.  This  arrangement  allows  of  the  re- 
moval of  the  square  of  towels  when  soiled  and  its  replacement  at 
necessary  intervals  during  the  operation  without  disturbing  the 
underlying  sheet. 


Fig.  120. — Operative  Field  Isolated  by  Celiotomy  Sheet. 


Fig.  121. — Side  View  of  Arrangement  of  Celiotomy  Sheet. 
168 


THE  OPERATING   ROOM   IN   PRIVATE   PRACTICE 


169 


DISPOSITION   OF   OPERATOR,   ASSISTANTS  AND   NURSES   DURING   THE 

OPERATION 

The  relationship  of  the  assistants  during  the  operation  to  the 
field  of  operation  should  be  considered  from  the  view  point  of 
expediency  and  with  the  view  of  forestalling  infection. 

The  prime  consideration  is  that  of  not  permitting  any  of  the 
assistants  or  the  apparatus  to  interfere  with  the  source  of  light. 
In  operations  on  the  ab- 
domen the  head  of  the 
patient  should  be  turned 
toward  the  light  if  the 
Trendelenburg  posture  is 
to  be  employed,  and  the 
feet  point  toward  the  light 
if  the  patient  is  to  remain 
flat  throughout  the  opera- 
tion. In  the  former  in- 
stance the  assistant  ad- 
ministering the  narcosis 
is  liable  to  throw  a  shadow 
on  the  field  of  operation, 
if  there  has  been  no  pro- 
vision made  for  reverse 
illumination  as  described. 
However,  this  obtains  only 

during  the  first  portion  of  the  operation  when  the  patient  is  still 
lying  flat.  When  the  Trendelenburg  posture  is  assumed  the  pa- 
tient's abdomen  will  be  higher  than  the  head  of  the  assistant  ad- 
ministering the  narcosis,  if  he  be  seated  (which  he  should  be),  and 
the  difficulty  mentioned  is  overcome.  This  calls  for  a  source  of 
light  as  high  up  as  is  feasible,  and  in  all  operations  this  should  be 
borne  in  mind.  The  illustration  (Fig.  124)  shows  a  serviceable 
arrangement  of  tables  and  assistants. 


Fig.     122. — Sterile    Towels     Arranged    in 
Manner  to  Surround  Operative  Field. 


THE   OPERATING   ROOM   IN   PRIVATE   PRACTICE 

Using  the  description  of  the  operating  room  as  described  as  a 
standard,  as  nearly  as  possible  an  arrangement  should  be  attempted 
when  operating  in  private  practice.      As  already  stated,   sterile 


170 


THE   OPERATING   ROOM 


material  for  wipes,  dressings,  sterile  towels  and  dressings  are 
obtainable  in  the  market,  packed  in  impervious  packages,  which 
simplifies  very  much  the  problem.  If  the  surgeon  have  not  at  his 
command  apparatus  which  will  sterilize  with  certainty  this  class 
of  material,  it  is  best  to  obtain  it  in  the  market.     As  regards  the 


Fig.  123. — Sterile  Towels  Applied  to  Surroundings  Contiguous  to 
Operative  Field. 


technic  of  sterilization,   this  has   already  been   described    (page 
62). 

Towels  and  sheets  are  perhaps  less  readily  obtainable  than 
dressings,  and  it  is,  under  these  circumstances,  at  times  necessary 
to  meet  the  indications  in  another  way.  The  writer  has  obtained 
favorable  results  as  regards  asepsis  in  private  practice  by  baking 
towels  and  sheets  and  gowns  in  the  kitchen  oven,  followed  by 


171 


172  THE  OPERATING   ROOM 

immersion  in  hot  bichlorid  solution  1  in  1,000  for  twenty  minutes. 
This  necessitates  the  wearing  of  a  wet  gown,  which  is  exceedingly 
uncomfortable;  however,  this  is  a  minor  objection.  Certain  it  is 
that  neither  the  gowns  nor  towels  or  sheets  may  be  regarded  as 
sterile  as  the  outcome  of  the  baking  process.  Again,  the  contact 
of  the  mercury  solution  with  instruments  destroys  them,  though 
this,  too,  is  a  minor  consideration. 

It  is  to  be  borne  in  miud  that  aseptic  results  are  more  readily 
obtained  in  private  practice  than  in  even  the  best  equipped  hos- 
pitals, though  the  technic  of  asepsis  seems  not  to  be  so  thorough. 
This  is  perhaps  due  to  the  probable  absence  of  pyogenic  bacteria 
in  private  residences  as  contrasted  with  hospitals,  where  infected 
cases  are  frequently  operated  upon. 

This  consideration,  however,  should  not  engender  a  com- 
placency which  may  be  the  causative  factor  in  an  unfavorable  out- 
come. The  chamber  selected  for  the  performance  of  the  opera- 
tion should  be  well  lighted  and  the  arrangement  of  the  necessary 
apparatus  so  designed  as  to  interfere  as  little  as  possible  with  this 
desideratum.  A  room  sufficiently  large  for  the  purpose  is  likely  to 
have  two  windows,  though  one  of  slightly  less  dimensions  with  one 
large  window  is  preferable,  as  the  operating  table  is  best  placed 
in  the  center  of  the  room,  and  the  shadow  of  the  space  between  the 
two  windows  falls  on  the  table  if  it  be  thus  placed.  If  a  room 
with  two  windows  is  used,  it  is  best  to  have  the  table  stand  in  the 
zone  of  light  from  one  of  them  and  arrange  the  accessory  para- 
phernalia accordingly. 

The  curtains  and  shades  should  be  removed  from  the  windows 
to  avoid  obscurity  of  illumination  from  this  cause,  though  their 
removal  is  imperative  for  other  reasons.  To  avoid  the  espionage 
of  curious  neighbors  the  window  glass  may  be  covered  with  a  thin 
layer  of  soap  applied  with  a  piece  of  gauze.  This  prevents  out- 
siders from  looking  into  the  room  and  does  not  interfere  markedly 
with  illumination.  If  the  room  is  to  be  prepared  on  the  same  day 
as  the  operation,  care  must  be  taken  not  to  make  sufficient  upheaval 
in  the  set  arrangement  of  the  room  to  provoke  dust  which  will  not 
have  time  to  settle  by  the  time  of  the  operation. 

In  this  instance  the  curtains,  shades,  hangings,  all  furniture 
and  pictures  should  be  carefully  removed,  taking  the  precaution  of 
wiping  them  off  with  a  damp  cloth  before  manipulating  them. 


THE  OPERATING   ROOM   IN   PRIVATE   PRACTICE  173 

The  carpet  should  not  be  removed,  but  may  be  covered  with  sheets 
dampened  with  a  solution  of  mercuric  chlorid  1  in  1,000.  The 
walls  should  be  gently  wiped  with  gauze  moistened  with  the  corro- 
sive sublimate  solution. 

If  the  operation  is  to  be  performed  more  leisurely,  the  pictures, 
shades,  hangings,  furniture,  including  carpets  and  ornaments,  are 
removed,  the  walls  dusted  and  the  windows  left  open  for  several 
hours,  during  which  the  dust  is  permitted  to  settle.  The  room  is 
then  fumigated  by  burning  sulphur  after  it  has  been  carefully 
sealed.  All  windows,  doors  and  chimney  joints  are  sealed  with 
gummed  paper  or  adhesive  plaster  strips.  The  sulphur  is  ignited 
at  night  and  the  resulting  fumes  permitted  to  remain  in  the  cham- 
ber until  the  following  morning.  The  room  is  then  opened,  the 
seals  removed  and  fresh  air  admitted.  The  walls,  ceiling  and 
floor  are  thoroughly  wiped  with  the  solution  of  bichlorid  of  mer- 
cury 1  in  1,000,  using  a  large  piece  of  gauze  for  the  purpose. 
When  the  mercury  solution  contained  in  a  piece  of  gauze  is  ex- 
hausted, it  is  thrown  away  and  a  clean  piece  used.  The  assistant 
who  does  the  wiping  should  be  admonished  not  to  rub  a  certain 
area  of  room  with  a  piece  of  gauze  and  then  resoak  it  in  the  solu- 
tion, but  to  throw  it  aside  and  use  a  fresh  supply.  The  floor  is 
scrubbed  with  green  soap  and  hot  water.  The  mantel  and  stationary 
furnishings  may  be  covered  with  clean  sheets.  The  latter  prepa- 
rations should  be  completed  for  several  hours  before  the  operation. 
In  the  interim  no  one  should  be  allowed  to  enter  the  chamber 
except  those  directly  concerned  in  the  operative  procedure. 

THE    OPERATING   TABLE 

The  transportation  of  an  operating  table  permitting  of  the 
elasticity  given  by  the  kind  of  apparatus  in  use  in  hospital  or  office 
practice  is  impracticable.  To  overcome  the  discomfort  of  the  im- 
provised table,  manufacturers  at  the  instigation  of  surgeons  have 
made  portable  tables  which  in  all  essential  regards  meet  the  indi- 
cations. A  number  of  these  portable  tables  are  on  the  market, 
each  one  of  which  has  its  exponents,  and,  indeed,  each  one  presents 
certain  advantages  over  the  other. 

Portable  Operating  Table. — The  table  shown  is  one  designed  by 
Dr.  J.  Bently  Squiers  of  ISTew  York  City,  constructed  of  cold- 
drawn  steel  tubing  fitted  with  milled  tool  steel  rack  and  pinion 


Fig.  125— Squiers'   Portable  Operating  Table,   Showing  Trendelenburg 
Posture  and  Crank  for  Obtaining  Same. 


Fig.  126.— Method  of  Folding  Squiers'  Portable  Operating  Table. 
174 


THE   OPERATING   ROOM   IN   PRIVATE   PRACTICE  175 

with  crank  for  elevating  the  top  (Fig.  125).  To  fold  the  table 
(Fig.  126)  it  is  only  necessary  to  fold  back  the  top,  which  is 
hinged  together,  bend  the  hinge  in  the  center  of  the  bottom  braces, 
which  fold,  and  the  two  ends  slide  together  by  the  side  braces  fold- 
ing. There  is  no  fastening  of  screws  or  clamps  necessary  to  set 
up  or  fold  the  table.  When  folded  for  transportation  the  table 
appears  as  shown  in  Fig.  127.     The  case  (Fig.  137)  is  extremely 


Fig.  127. — Squiers'  Portable  Operating  Table  Folded  for  Transportation. 

light  and  is  fitted  with  a  handle.  The  weight  of  the  table  is  28 
pounds.  The  Trendelenburg  posture  is  shown  in  Fig.  125.  For 
operations  on  the  head  and  face  the  head-piece  is  raised  or  lowered 
as  desired;  the  arrangement  for  lithotomy  position  is  shown  in 
Fig.  128.  The  dimensions  of  the  table  are  19  inches  wide,  67 
inches  long  and  34  inches  high.  When  folding  for  transportation, 
the  dimensions  are  6  inches  thick,  20  inches  wide  and  35  inches 
long.  This  table  may  be  regarded  as  forming  a  standard.  Modi- 
fications of  construction  to  suit  the  taste  and  class  of  practice  of 
the  surgeon  are  simple  questions  of  mechanical  art. 

The  portable  apparatuses  designed  to  be  placed  on  the  ordi- 
nary deal  table  to  permit  of  Trendelenburg  posture,  lithotomy 
position,  etc.,  are  also  much  in  vogue.  These  are  extremely  use- 
ful and  satisfactorily  efficient,  if  it  be  not  necessary  to  change  the 
posture  of  the  patient  during  the  operation.  The  disturbance  of 
the  arrangement  of  the  sterile  surroundings  consequent  upon  the 
manipulations  involved  under  these  conditions  makes  them  less 
acceptable  than  a  table  fitted  with  legs,  as  the  Squiers  table  or  a 
similar  apparatus. 


176 


THE   OPERATING   ROOM 


The  additional  weight  of  the  frame  and  legs  is  a  minor  con- 
sideration. On  general  principles  a  portable  table  should  be  de- 
signed with  the  view  of  obtaining  the  greatest  elasticity  as  regards 
necessities  which  may  arise,  and  there  can  be  no  doubt  that  the 
kind  of  table  here  described  is  constructed  with  this  in  view. 


Fig.  128. — Squiers'  Portable  Operating  Table  Arranged  for  Lithotomy 

Position. 


An  operation  for  removal  of  a  neoplasm  of  the  neck  which  is 
to  be  performed  in  the  patient's  home  calls  for  neither  a  portable 
complete  table  nor  an  adjustable  frame,  and  in  this  instance  the 
ordinary  deal  table  is  of  sufficient  utility.  Indeed,  it  may  be  said 
that  the  display  of  unnecessary  armamentarium  in  surgical  work 
is  undesirable ;  yet  the  portable  operating  table  is  Avell  nigh  indis- 
pensable in  operations  on  the  abdominal  and  pelvic  organs. 


THE  OPERATING   ROOM   IN   PRIVATE   PRACTICE 


177 


The  Extemporized  Operating-  Table. — For  this  purpose  the  or- 
dinary deal  kitchen  table  makes  a  useful  substitute  in  operations 


Fig.  129. — Extemporized  Operating  Table. 

blanket. 


Kitchen  table  covered  with 


which  permit  of  the  supine  position  and  may  be  tilted  to  obtain 
a  moderate  degree  of  Trendelenburg  elevation.  However,  it  is  to 
be  remembered,  as  already  stated,  when  the  Trendelenburg  posture 


Fig.  130. — Extemporized  Operating  Table  Covered  with  Blanket  and 

Rubber  Sheet. 

or  the  lithotomy  position  is  necessary,  special  apparatus  for  the 
purpose  should  be  employed. 


178  THE   OPERATING   ROOM 

The  deal  table  usually  found  in  kitchen  or  laundry  is  more 
useful  than  the  dining-room  table,  as  the  latter  is  likely  to  be  too 


Fig.  131. — Small  Pillow  and   Sheet  Placed  ox  Extemporized  Operating 

Table. 

wide  to  allow  of  easy  access  to  the  patient  from  both  sides.     The 
kitchen  table  should  be  covered  with  a  folded  blanket  (Fig.  129) 


Fig.  132. — Drainage  Pad  Placed  ox  Extemporized  Operatixg  Table. 

in  order  to  prevent  pressure  soreness  following  the  operation.    Xext 
a  rubber  sheet  (Fig.  130)  is  placed  on  the  blanket  and  this  covered 


THE   OPERATING   ROOM   IN   PRIVATE   PRACTICE 


179 


with  a  sheet  and  a  small  pillow  (Fig.  131)  placed  in  situ  for  the 
patient's  head.  Drainage  is  provided  with  the  Kelly  pad  (Fig. 
132),  the  pad  being,  of  course,  placed  on  the  portion  of  the  table 
corresponding  to  the  part  to  be  operated  upon.     The  bottom  of  the 


111  K^ra 


Fig.  133. — Kelly  Pad  Arranged  on  Extemporized  Operating  Table,  to 
drain  into  Pail. 


pad  is  folded  over  and  led  into  a  pail  (Fig.  133).  Care  should 
be  exercised  in  selecting  a  table  with  firm  strong  legs,  as  the  com- 
bined weight  of  the  patient  and  the  fact 
that  the  operator  and  assistant  are  likely  to 
lean  on  the  table  are  apt  to  break  the  legs 
off  where  they  join  the  top.  If  there  be  any 
doubt  as  to  the  stability  of  the  table,  it  may 
be  reinforced  by  wiring  the  legs  together 
near  their  bottoms. 

If  the  lithotomy  position  is  to  be  em- 
ployed, the  apparatus  shown  in  Fig.  134 
will  be  found  extremely  useful.  The 
clamps  are  readily  fastened  to  any  table 
and  the  uprights  are  maintained  at  any 
height  by  means  of  the  set  screws.  At  sub- 
sequent dressings,  the  clamps  may  have  the 
stirrup  shown  in  Fig.  135  inserted  instead 
of  the  upright. 
14 


Fig.  134.  —  Clamps  and 
Uprights  for  Lith- 
otomy Position  on 
Extemporized  Oper- 
ating Table. 


180 


THE  OPERATING   ROOM 


Tables  for  narcotist,  suture  material,  instruments  and  dress- 
ings are  readily  extemporized  from  those  ordinarily  found  in  dwell- 
ings.    As  a  matter  of  fact, 
the  operating  table  and  one 
table  (Fig.  186)  are  perhaps 
the  only  portable  apparatuses 
necessary.     Fig.  137  shows  a 
case   which   will   carry  both 
the  portable  operating  table 
and  the  small  metal  table  for 
instruments,   which   may  be 
placed   close   to   the   surgeon 
and  take  the  place  of  the  ad- 
justable instrument  tray. 
Dressings,  wipes,  etc.,  have  already  been  taken  up  (page  158). 
Their  disposition  in  the  improvised  operating  room  need  not  differ 
materially  from  that  which  obtains  in  hospital  operating  rooms. 


Fig.  135. — Clamp  and  Stirrup  for  Extem- 
porized Operating  Table. 


Fig.  136. — Portable  Operating  and  Instrument  Table. 


STERILE  WATER 


The  question  of  sterile  water  is  not  solved  by  the  presence  of 
several  gallons   of   distilled  water.      Distilled  water,   as   already 


THE   OPERATING   ROOM   IN   PRIVATE   PRACTICE  181 

stated,  is  not  sterile,  though  boiled  water  which  is  used  soon  after 
boiling  is  practically  sterile.  In  this  contingency  it  is  well  to  boil 
the  distilled  water  in  a  large  wash  boiler  and  to  fill  the  pitchers 
with  a  dipper  which  has  been  boiled  with  the  water.  Frequent 
immersion  of  the  hand  into  the  wash  boiler  in  order  to  manipulate 
the  dipper  is  objectionable.  This  may  be  obviated  by  the  use  of 
a  dipper  with  a  sufficiently  long  handle  to  protrude  over  the  top 
of  the  boiler,  a  corner  of  the  boiler  cover  being  notched  for  the 


Fig.  137. — Portable  Operating  and  Instrument  Table  Folded  for 
Transportation,  and  Case  for  Same. 

purpose,  though  this  should  not  be  done  until  after  the  boiler  has 
been  exposed  to  high  temperature. 

An  exceedingly  useful  method  of  handling  water  is  used  by 
Lesser.  A  flask  of  thin  glass,  especially  prepared  to  withstand 
high  temperature,  is  filled  with  distilled  water  and  the  mouth 
covered  with  cotton  between  two  layers  of  gauze  (Fig.  138). 
The  neck  of  the  bottle  has  a  piece  of  wire  twisted  about  it,  by 
means  of  which  it  is  suspended  when  used  as  an  irrigator.  A 
number  of  these  bottles  are  placed  directly  on  the  fire  (Fig.  138), 
and  the  water  boiled  for  twenty  minutes.  A  Bunsen  burner  may 
be  used,  or  the  flask  may  be  placed  on  the  kitchen  stove.  For  the 
purpose  of  lavaging  the  parts  the  non-sterile  nurse  simply  lifts 


Fig.  138. — Flask  Filled  with  Water,   W  hich  is  Boiled  for  Twenty 
Minutes  Immediately  before  Use. 


Fig.  139. — Flask  of  Sterile  Water  with  Rubber  Tube  Connection 
for  Irrigation. 
182 


THE   OPERATING   ROOM   IN   PRIVATE   PRACTICE 


183 


the  gauze  cover  and  pours  the  contents  on  the  surface  to  be 
cleansed.  For  irrigation  the  cotton  plug  is  removed  and  a  rubber 
cork  pierced  with  a  bent  glass  tube  is  substituted.  The  portion 
of  glass  tube  in  the  bottle  is  connected  with  a  piece  of  soft  rubber 
tubing,  the  end  of  which  is  covered  with  gauze  for  the  purpose 
of  avoiding  the  abstraction  of  foreign  particles  in  the  event  of  the 
water  not  being  distilled.  If  the  water 
has  been  distilled  the  gauze  screen  is 
not  used. 

The  portion  of  glass  tube  protruding 
is  connected  with  a  long  piece  of  rubber 
tubing  (Fig.  139).  To  withdraw  the 
water,  the  tubing  and  glass  tube  and 
cork  are  submerged  in  sterile  water 
and  filled.  This  constitutes  a  siphon, 
and  the  connection  with  the  reservoir 
is  made  as  shown  (Fig.  139).  The 
tube  is  closed  with  a  clamp  when  not 
in  use.  Midway  between  the  bottle  and 
the  terminal  end  of  the  rubber  tubing 
is  connected  a  glass  tube  with  a  bulbed 
enlargement.  This  gives  opportunity 
for  standardizing  the  flow  of  water  in 
washing  into  cavities.  It  also  permits 
of  recognition  of  the  flow  in  itself,  thus 
obviating  the  annoyance  of  doubt  as  to 
whether  the  fluid  is  flowing  or  not. 
Fig.  140  shows  the  bulb  connection, 
which    in    this    instance    was    partially    Fig.  uo.— Glass  Bulb  Cox- 

r*TT      t  •<!  -t,-  c  ,  •  NECTION  IN   RUBBER   TUBE 

filled  with  a  solution  of  potassium  per-         to    CoNTROL    Flow    of 
manganate    to    favor    clearness    in    the         Irrigating  Fluid. 
illustration. 

Fig.  141  shows  the  irrigating  apparatus  suspended  from  a 
stand.  In  private  practice  an  ordinary  clothes  hook  placed  in  a 
convenient  situation  may  be  employed.  The  basin  near  the  bot- 
tom of  the  stand  is  filled  with  a  solution  of  bichlorid  of  mercury 
1  in  1,000.  In  this  instance  the  bulb  is  submerged  in  the  basin. 
Care  must  be  taken  not  to  contaminate  the  tube  connections  when 
the  siphonage  is  arranged. 


184 


THE   OPERATING  ROOM 


The  advantage  of  the  method  lies  in  the  fact  that  the  water 
is  sterilized  in  the  container,  from  which  it  is  delivered  on  the 
operative  field  without  intermediate  handling. 

Theoretically  this  method  of  sterilizing  and  employing  water 
should  be  more  certain  than  one  which  involves  handling  of  the 
water  between  the  sterilizer  and 
the  wound.  However,  the  in- 
flexibility of  the  method  with 
respect  to  the  adjustment  of 
desirable  ranges  of  tempera- 
ture, and  the  fact  that  the  ap- 
paratus now  employed  for  the 
purpose  is  so  well  arranged, 
would  argue  for  employment 
of  the  latter  in  hospitals  and 
sanatoria,  leaving  the  flask 
method  for  use  in  private  prac- 
tice. 

It  is  of  course  feasible  to 
sterilize  water  by  other  means 
than  those  shown  here.  For 
instance,  there  is  no  reason 
why  containers  other  than  those 
made  of  glass  should  not  be 
employed  for  the  purpose,  pro- 
vided the  principle  of  not 
handling  the  water  after  it  is 
boiled  is  borne  in  mind.  In 
the  event  of  the  water  thus 
treated  being  too  hot,  the  flasks 
may  be  immersed  in  cold 
water    for    varying    periods    of 

time,  in  accord  with  the  desired  temperature.  It  is  a  good  plan, 
if  feasible,  to  boil  all  the  flasks  twenty-four  hours  before  the  oper- 
ation and  heat  half  of  them,  to  almost  the  boiling  point,  im- 
mediately before  the  operation.  Thus  the  surgeon  has  at  his 
disposition  water  of  quite  extreme  temperature,  a  condition  of 
affairs  which  permits  of  considerable  adjustability  in  this  con- 
nection. 


Fig.  141. — Flask  Used  as  Irrigator 
Suspended  by  Wire  Attached  to 
Neck. 


THE   OPERATING   ROOM   IN   PRIVATE   PRACTICE  185 

SUTURE   AND   LIGATURE   MATERIAL 

Suture  and  ligature  material  in  private  practice  is  used  in  the 
same  form  as  obtains  in  hospital  practice.  However,  the  transpor- 
tation of  suture  material  which  will  not  stand  boiling  is  unsafe, 
unless  it  be  inclosed  in  sterile  tubes  (Fig.  53).  Silk,  silk-worm 
gut  and  celluloid  thread  (Pagenstecher  thread),  may  be  safely 
transported  and  boiled  with  the  instruments  or  separately.  It  is 
to  be  borne  in  mind  that  iodine  catgut  will  not  stand  heat,  and, 
if  used  from  sealed  tubes,  the  tubes  must  be  sterilized  by  pro- 
longed immersion  in  strong  antiseptic  solutions,  which  latter  may 
be  diluted  with  sterile  water  immediately  before  handling  the 
tubes  to  prevent  the  chemical  action  of  the  antiseptic  upon  glove 
or  hand. 

As  a  general  proposition,  it  may  be  said  that  operations  in 
private  houses  are  less  liable  to  be  complicated  with  wound  infec- 
tion, and  that  the  results  obtained  in  operating  under  these  con- 
ditions are  uniformly  good,  though  the  technic  of  the  surgeon  is 
somewhat  hampered  by  the  inflexibility  of  the  operating  table 
and  by  the  fact  that  the  source  of  light  is  not  as  readily  made  as 
serviceable  as  obtains  in  hospital  practice. 

On  the  whole,  a  surgeon  supplied  with  a  portable  table,  and 
whose  assistants  exercise  reasonable  care  in  the  technic  of  achiev- 
ing cleanliness,  is  in  a  position  to  do  satisfactory  work  in  patients' 
homes. 


CHAPTEK    VIII 
DRAINAGE  OF  OPERATIVE  WOUNDS 

Drainage  in  uninfected  cases — Drainage  in  infected  cases — Drainage  agents: 
— Tube  drainage;  silk- worm  gut  drainage;  catgut  drainage;  rubber  tissue 
drainage;   textile  fabric  drainage. 

The  drainage  of  operation  wounds,  the  question  of  its  intro- 
duction, its  maintenance,  and  the  length  of  time  agents  intro- 
duced for  the  purpose  of  drainage  should  remain  in  situ  are 
important  factors  in  the  treatment  of  wounds,  the  outcome  of 
surgical  procedure. 

It  may  be  said,  in  a  general  way,  that  drainage  of  operation 
wounds  is  not  as  universally  employed  at  this  time  as  has  ob- 
tained in  the  past.  A  clearer  understanding  of  the  processes  of 
repair  of  surgical  trauma  and  the  part  taken  by  secretions,  the 
result  of  reparative  process,  and  a  better  knowledge  of  the  ability 
on  part  of  the  body  to  take  care  of  certain  exudates  are  respon- 
sible for  this. 

Yet  it  is  to  be  understood  that  drainage  has  a  clear  and  def- 
inite place  in  surgical  technic,  and  that,  while  an  unfavorable 
outcome  may  result  if  it  is  not  employed,  rarely  indeed  would  its 
establishment  be  followed  by  other  than  delay  in  repair  of  the 
wound  or  possibly  in  the  abdomen,  by  the  occurrence  of  hernia. 
Certain  it  is  that,  if  it  be  doubtful  in  the  mind  of  the  surgeon 
whether  drainage  in  a  given  case  is  to  be  established  or  not,  it  is 
wisest  to  employ  it.  Indeed,  in  these  doubtful  cases  the  subse- 
quent behavior  of  the  case,  as  determined  by  the  symptomatology, 
will  not  infrequently  permit  of  the  removal  of  the  drainage  agent 
at  a  time  when  the  reparative  process  would  have  been  so  little 
interfered  with  as  to  practically  preclude  the  likelihood  of  hernia 
or  undesirable  cosmetic  outcome. 

In  a  general  way  it  may  be  said  that  infection  in  the  opera- 
tion field  calls  for  drainage,  the  absence  of  infection  justifies  dis- 

186 


DRAINAGE   IN   UNINFECTED   CASES  187 

regarding  it.  However,  there  are  situations  and  conditions  where 
infection  is  present  when  drainage  is  not  alone  unnecessary,  but  a 
prejudice  to  the  best  possible  ultimate  outcome,  such  as  the  re- 
moval of  pyosalpinx  by  the  abdominal  route,  in  which  instance 
the  character  of  pus  is  such  as  to  render  drainage  unnecessary, 
and  the  presence  of  a  drain  extending  through  the  abdominal  wall 
favors  the  occurrence  of  ventral  hernia,  while  the  irritation  of  the 
peritoneum  arising  from  the  presence  of  the  drain  agent  is  liable 
to  produce  adhesions  of  the  abdominal  contents  which  are  un- 
desirable. 

Again,  if  the  operation  field  be  extensive,  such  as  obtains  in 
the  removal  of  large  neoplasms,  and  there  has  been  much  trauma 
to  the  surrounding  tissues,  the  conditions  are  exceedingly  favor- 
able to  the  development  of  infection,  the  outcome  of  accidental 
fertilization.  Under  these  conditions  it  would  be  best  to  establish 
drainage. 

It  may  also  be  said  that  the  necessity  for  drainage  in  unin- 
fected operative  cases  bears  a  direct  proportion  to  the  thorough- 
ness with  which  hemorrhage  has  been  arrested.  The  presence  of 
blood  clots  in  the  blind  spaces  of  an  extensive  wound  favors  infec- 
tion, and  the  forcible  manipulation  of  wounds  of  dimensions  in- 
adequate to  the  gentle  manipulation  of  the  area  invaded  also 
markedly  favor  the  development  of  infection. 

If,  on  the  other  hand,  the  complete  arrest  of  all  oozing  in  a 
wound  of  extensive  dimensions  is  going  to  prolong  the  surgical 
manipulations,  and  possibly  call  for  the  use  of  excessively  hot 
solutions  or  strong  astringents  in  order  to  arrest  it,  it  would  be 
wisest  to  introduce  drainage  in  order  to  permit  of  the  discharge 
of  serum  and  the  expulsion  of  blood  clots  early  during  the  process 
of  repair. 

The  necessity  for  drainage  in  a  given  class  of  cases  is  perhaps 
best  taken  up  in  the  discussion  of  the  care  of  operation  wounds 
under  the  special  heads,  and,  indeed,  this  will  be  found  done. 
However,  the  general  principles  involved  are  properly  taken  up 
at  this  time. 

DRAINAGE    IN   UNINFECTED   CASES 

The  theory  of  drainage  in  cases  where  infection  does  not  exist 
at  the  time  of  the  operation  is  to  either  remove  secretions,  the  out- 


188  DRAINAGE  OF   OPERATIVE   WOUNDS 

come  of  the  process  of  healing,  which  would  prejudice  complete 
and  rapid  repair,  or  to  provide  an  avenue  of  escape  for  infective 
material  which  may  have  been  accidentally  introduced  during  the 
operation.  The  exudate  consequent  upon  the  process  of  non-sup- 
purative  repair  ceases  at  the  end  of  three  times  twenty-four  hours 
after  the  operation,  and  infection  introduced  during  the  operation 
should  manifest  itself  in  modification  of  the  normal  expression  of 
metabolism,  i.e.,  temperature  and  pulse  rate,  within  that  time. 

What  exudate  occurs  during  this  period  of  time  may  be  re- 
garded as  physiological  if  no  infection  has  been  introduced.  This 
means  that  at  the  end  of  this  time  the  drainage  agent  may  be  re- 
moved if  there  be  no  indication  to  the  contrary.  The  drainage, 
too,  will  have  filled  its  office  in  having  maintained  an  avenue  of 
escape  for  non-infected  exudates  which  might  mechanically  inter- 
fere with  union,  and  therefore  it,  too,  may  be  removed. 

Taking  into  consideration  the  longer  period  of  incubation  of 
infective  processes,  the  character  of  which  is  of  so  little  virulence 
as  to  require  a  longer  period  of  time  than  this  to  develop,  and 
which  may  be  regarded  as  capable  of  no  greater  harm  than  local 
manifestations  of  minor  import  and  the  consequent  pathologic 
process,  they  are  readily  taken  care  of  with  less  unfavorable  out- 
come to  the  ultimate  result  than  would  obtain  had  the  drainage 
been  prolonged.  Certainly  it  is  warrantable  to  assume  that  no 
particularly  dangerous  occurrence  will  manifest  itself  later  than 
the  fourth  day  after  the  operation,  and  the  infrequent  times  when 
late  infection  occurs  does  not  justify  jeopardizing  the  chances  of 
a  favorable  immediate  outcome  by  over-precaution,  more  so  as 
in  the  vast  majority  of  cases  the  practice  suggested  has  been  found 
to  be  a  good  one,  as  the  outcome  of  prolonged  experience  in  cases 
of  this  sort. 

DRAINAGE   IN   INFECTED    CASES 

Drainage  in  infected  cases  is  most  generally  necessary.  The 
instances  when  it  may  be  ignored  are  rare,  though  it  may  be  said 
that  infections  of  organs  covered  by  peritoneum  make  the  excep- 
tion, i.e.,  an  infected  organ  which  is  attacked  by  the  surgeon 
through  its  peritoneal  covering  does  not  necessarily  call  for  drain- 
age of  the  entire  peritoneal  sac. 

This  exception  relates,  however,  only  to  instances  in  which 


DRAINAGE   AGENTS  189 

the  infective  process  in  the  given  part  is  of  a  character  which  jus- 
tifies the  belief  that  the  virulence  of  the  infective  process  has  been 
exhausted  as  the  result  of  a  prolonged  combat  between  the  in- 
vading infection  and  the  resistance  of  the  part,  and  the  operating 
is  undertaken  for  the  relief  of  pain  and  affliction,  the  outcome  of 
a  now  quiescent  process,  or  with  the  view  of  forestalling  occasional 
exacerbation  of  the  disease  and  possible  excursions  into  contiguous 
parts,  organs,  and  tissues. 

Again,  drainage  may  be  discarded  in  cases  where  the  infection 
has  not  jet  markedly  involved  the  peritoneum,  and  the  operation 
radically  removes  totally  the  source  of  infection.  This  contention 
is  elastic,  however,  in  the  sense  that  a  moderate  amount  of  infec- 
tion of  the  peritoneum  will  recover  without  drainage  for  the  rea- 
son that  the  causative  focus  has  been  removed  and  that  the  peri- 
toneum will  take  care  of  a  certain  amount  of  exudate,  provided 
this  be  not  fluid  pus. 

Another  consideration  which  influences  the  decision  in  this 
regard  is  the  fact  that  localized  areas  of  peritoneum  are  not  drained 
by  the  introduction  of  drainage  agents  unless  the  area  be  isolated 
by  adhesions,  and  if  this  be  not  the  case,  it  is  a  question  whether 
the  surgeon  is  justified  in  running  the  risk  of  contaminating  con- 
tiguous healthy  portions  of  the  peritoneum  in  an  attempt  to  obtain 
dependent  drainage.  However,  this  is  more  largely  taken  up  in 
connection  with  the  after-treatment  of  abdominal  operations. 

In  the  presence  of  free  pus  in  this  situation,  or  if  there  be  a 
reasonable  assurance  that  the  area  of  operation  has  been  exposed 
to  infection,  drainage  should  be  always  employed.  It  is  a  firmly 
established  rule  in  surgery  that  all  drainage  should  aim  to  exercise 
its  office  at  the  most  dependent  portion  of  the  area  of  operation, 
and  should  be  so  arranged  as  not  to  be  interfered  with  as  the  result 
of  a  posture  on  part  of  the  patient  which  would  render  futile  the 
intent. 

DRAINAGE   AGENTS 

TUBE   DRAINAGE 

Tube  drainage  is  employed  in  cases  where  large  quantities  of 
fluid  pus  is  to  be  removed ;  also  in  cases  of  extensive  trauma  where 
there  is  a  reasonable  inference  that  from  the  character  of  the  injury 
extensive  infection  is  liable  to  be  manifested.     It  is  rarely  used  in 


190  DRAINAGE   OF   OPERATIVE   WOUNDS 

clean  operative  wounds,  even  though  exudates  are  likely  to  occur, 
in  which  latter  instances  other  drains  are  employed. 

Glass  tubing  has  been  quite  abandoned  except  in  cases  of  tuber- 
culous peritonitis  and,  perchance,  for  drainage  of  empyema. 

Rubber  tubing  has  quite  displaced  all  other  material.  Rubber 
tubes  should  be  of  sufficient  caliber  to  take  care  of  the  indications, 


Fig.  142. — Glass  Jar  Containing  Rubber   Drainage  Tubes  of  Various  Sizes, 
Submerged  in  Corrosive  Sublimate  Solution  1  in  1,000. 

with  a  slight  excess  of  size  beyond  what  is  expected  in  a  given  case. 
Drainage  should  not  be  indiscriminately  used,  but  when  employed 
should  be  ample  for  the  purpose.  The  quality  of  rubber  used  is 
important,  as  sterilization  by  heat  is  exceedingly  desirable  and  in- 
ferior quality  of  rubber  disorganizes  when  exposed  to  great  heat. 
In  hospitals  and  office  practice  rubber  tubing  of  various  caliber 


DRAINAGE  AGENTS 


191 


is,  after  being  boiled,  kept  in  glass  jars  submerged  in  aqueous  solu- 
tion of  bichlorid  of  mercmy  1  in  1,000  (Fig.  142).  This  prac- 
tice is  not  safe,  as  the  removal  of  a  portion  of  the  contents  may 
result  in  accidental  fertilization.  Care  should  be  taken  to  remove 
the  portion  of  tubing  to  be  used  with  sterile  forceps. 

In  private  practice  tubing  of  the  desired  caliber  is  sterilized 
in  a  glass  container  in  which,  after  hav- 
ing been  boiled,  it  is  placed,  together 
with  a  sufficient  quantity  of  water,  and 
again  exposed  to  heat.  The  container 
is  then  sealed,  and  fertilization  during 
transportation  or  while  stored  is  im- 
possible. This  is  the  safest  method  of 
handling  rubber  tubes  for  drainage. 
However,  it  is  quite  proper  to  convey 
non-sterile  tubing  to  the  scene  of  opera- 
tion and  boil  it  with  the  instrument  or 
separately.  This  is  a  thoroughly  effi- 
cient method  provided  the  tubing  be 
used  immediately. 

When  using  the  tube  it  is  cut  to 
the  desired  length  and  fenestrated  as 
shown  in  Fig.  143.  When  cutting  the 
fenestra  a  curved  scissors  should  be 
used  to  make  oval  openings.  If  the 
tube  be  bent  at  an  acute  angle  and  tri- 
angular pieces  be  cut  out  with  straight 
scissors,  the  resultant  fenestrum  is  dia- 
mond-shaped, and  the  tube  is  liable  to 
kink  at  this  point  and  become  obliter- 
ated when  placed  in  situ.  In  order  to 
prevent  the  tube  from  slipping  into  the 
cavity  it  is  draining,  a  safety  pin  is 
fastened   to  its   protruding  end   in  the 

manner  shown  in  Fig.  143.  The  pin  should  be  pushed  through 
the  side  of  the  tube  and  not  cross  the  caliber  of  the  tubing  at  its 
center  to  avoid  obstruction  of  the  flow  of  discharges. 

The  protrusion  of  the  tube  beyond  the  skin  should  be  as  slight 
as  possible,  just  sufficient  to  allow  for  the  safety  pin  and  a  pad 


Fig.  143. — Rubber  Drain- 
age Tube  Fenestrated 
and  Safety  Pin  At- 
tached. 


192 


DRAINAGE   OF   OPERATIVE   WOUNDS 


of  gauze  underneath  the  latter.  This  precaution  avoids  oblitera- 
tion of  the  end  of  the  tube  by  pressure  from  the  protective  dressing 
(Fig.  144).  The  object  of  the  gauze  pad  is  to  prevent  contact  of 
the  pin  with  the  wound,  which  might  cause  irritation  if  this  pre- 
caution were  not  taken. 

Tube  drainage  being  usually  employed  for  the  drainage  of  pus 


Fig.  144. — Rubber  Tube  Drainage  in  situ. 


cavities,  the  dressing  is  changed  at  frequent  intervals.  This  is 
the  more  imperative  at  the  expiration  of  the  twenty-four  hours 
following  the  operation  because  the  trauma  resulting  from  the 
surgeon's  manipulations  causes  a  certain  amount  of  hemorrhage. 
The  oozing  of  blood  into  a  cavity  causes  the  formation  of  blood 
clot,  and  this  is  liable  to,  and,  indeed,  most  usually  does,  invade 
the  tube,  obstructing  its  lumen.      Therefore,   the   tube  should  be 


DRAINAGE   AGENTS 


193 


removed  at  the  end  of  twenty- four  hours,  the  clot  from  the  lumen 
and  those  formed  in  the  cavity  expressed,  and  the  tube  reinserted. 
Disregard  of  this  precaution  frequently  leads  to  constitutional  dis- 
turbances, the  outcome  of  absorption  of  the  retained  secretions. 


Fig.  145. — Triplex  Rubber  Drainage  Tube. 


A  so-called  triplex  drainage  tube  has  recently  been  employed 
by  the  writer  with  success.  The  tube  is  made  of  pliable  rubber 
(Fig.  145),  and  consists  of  three  small  tubules  molded  together. 
The  smaller  lumen  acts  slightly  like  a  capillary  tube.  The  ar- 
rangement also  permits  of  washing  of 
a  cavity  through  one  of  the  openings, 
while  the  other  two  furnish  ample 
avenue  of  escape  of  secretions  and 
allow  of  free  escape  of  the  cleansing 
fluid.  Fig.  146  shows  a  transverse 
section  of  the  tube. 

SILK-WORM   GUT  DRAINAGE 

Silk-worm    gut    is    employed    for 
drainage    purposes     in    cases     where 

,iii  i  -.i     ,i  Fig.    146. — Transverse    Sec- 

tnere  has  been  much  oozing,  with  the  ™  „„„„  nT7„Di:,„ 

o'  tion   or  Triplex  Rubber 

view  of  draining  off  serum  and  fluid  Drainage  Tube. 


194 


DRAINAGE  OF  OPERATIVE  WOUNDS 


blood.  It  is  rarely  used  when  infection  exists  at  the  time  of  the 
operation,  though  in  the  event  of  a  small  abscess  cavity  being 
present,  it  may  be  used  in  place  of  tube  drainage.  It  is  often 
employed  in  cases  of  removal  of  tuberculous  glands  which  have 
no  surrounding  mixed  infection,  and  the  operator  feels  that  drain- 
age for  a  few  days  is  a  wise  precautionary  measure. 

For  the  purpose  several  strands  of  silk-worm  gut  are  used,  the 
number  employed  depending  upon  the 
area  requiring  the  measure,  which  are 
looped  in  the  manner  shown  in  Fig. 
147.  The  loop  spreads  out  the  under- 
lying cavity,  and  by  capillarity  the 
fluid  exudate  is  caused  to  emerge  at 
the  twisted  ends.  In  cases  of  moderate 
infection  a  strand  at  a  time  may  be 
removed  from  the  wound  as  the  dis- 
charge becomes  less,  thus  maintaining 
drainage  in  proportion  to  the  indica- 
tions. Fig.  148  shows  the  silk-worm 
gut  drain  placed  in  situ. 

CATGUT  DRAINAGE 

Catgut  drainage  is  employed  in 
much  the  same  way  as  is  silk-worm 
gut.  It  is,  however,  never  used  in  the 
presence  of  purulent  infection.  It  has 
the  presumable  advantage  of  being  ab- 
sorbed and  need  not  be  removed.  In  a 
clean  case  its  employment  assures  an 
avenue  of  escape  for  the  fluid  exudates, 
and  the  fact  that  it  is  absorbed  prevents 
the  necessity  of  disturbing  the  dress- 
ings in  order  to  remove  it.  It  is  also 
employed  in  operations  upon  bones  fol- 
lowing which  absolute  immobilization 
is  desirable,  and  is  exceedingly  serviceable  when  complete  rest  of 
the  part  is  regarded  as  essential.  On  the  whole,  it  may  be  re- 
garded as  having  an  exceedingly  restricted  field  of  usefulness. 
Fig.  149  shows  the  arrangement  of  the  catgut  for  the  purpose. 


Fig.  147.  —  Silk-worm  Gut 
Looped  for  Drainage 
Purposes. 


DRAINAGE  AGENTS 


195 


It  is  wiser  to  use  a  large  number  of  strands  of  fine  catgut  than  a 
few  heavy  ones,  for  the  reason  that  offensive  exudates  are  more 
thoroughly  removed  by  having  the  way  of  egress  indicated  in 
multiplicity,  and  the  circulating  fluid  is  more  apt  to  act  quickly 


Fio.  148. — Silk-worm  Gut  Drain  in  situ. 


if  the  surface  exposed  to  absorption  is  large, 
catgut  drain  in  situ. 


Fig. 


150  shows 


RUBBER  TISSUE   DRAINAGE 

Rubber  tissue  for  drainage  is  employed  in  much  the  same  class 
of  cases  as  silk-worm  gut  and  tube  drainage,  except  that  it  should 
be  used  to  drain  cavities  of  moderate  dimensions.  The  rubber  tis- 
sue is  prepared  by  boiling  and  is  stored  in  a  flat  glass  dish  sub- 
merged in  sterile  saline  solution  (Fig.  151). 

For  the  purpose  of  drainage  the  tissue  is  cut  to  the  desired 
15 


196 


DRAINAGE   OF   OPERATIVE  WOUNDS 


size  and  rolled  upon  itself  into  a  tubular  form  (Fig.  152).  Silk- 
worm gut,  catgut,  and  rubber  tissue  drains  are  not  cut  at  the  level 
of  the  skin,  but  are,  because  dependent  upon  capillarity  for  action, 

j)ermitted  to  protrude  to  a  considerable 
extent  from  the  wound. 

All  of  these  agents  act  better  when 
the  portion  of  protective  dressing  with 
which  they  are  in  immediate  contact  is 
moistened  with  sterile  water,  as  capil- 
larity is  more  effective  when  it  need 
not  overcome  the  resistance  of  non-satu- 
rated surroundings.  The  rationale  of 
this  is  illustrated  by  the  housewife  who 
moistens  a  new  lamp-wick  at  the  burner 
before  she  attempts  to  ignite  it.  Rubber 
tissue  drains  have  the  advantage  of  not 
forming  attachment  to  the  tissues,  and 
thus  interference  with  action  is  not 
likely  to  occur.  Also,  when  they  are 
removed,  the  edges  of  the  wound  are  not 
disturbed,  and  the  patient  is  saved  pain 
and  annoyance 
tissue  drain  in  situ 


Fig.  153  shows  rubber 


Fig.  149. — Catgut  Arranged 
for  Drainage. 


TEXTILE   FABRIC  DRAINAGE 

Various  forms  of  medicated  gauze 
are  used  for  the  purpose.  Their  action 
is  similar  to  that  of  the  preceding.  As 
a  general  rule,  it  may  be  said  that  drains  which  act  by  capillarity 
should  take  the  place  of  tube  drainage  when  dependent  drainage 
cannot  be  obtained.  Tubes  will  not  drain  "  up  hill  " ;  capillary 
drains,  while  not  as  effective  when  draining  upward,  still  will  act 
when  not  placed  in  dependent  positions.  Textile  fabric  presents 
the  best  mechanical  agent  to  accomplish  the  purpose.  However, 
gauze  is  not  resistant  to  pressure,  becomes  adherent  to  the  sur- 
rounding tissues,  and  thus  its  action  is  considerably  interfered 
with.  To  obviate  these  objections,  the  so-called  "  cigarette  drain  " 
has  come  into  use. 

It  consists  of  gauze  rolled  to  the  desired  thickness,  the  diam- 


DRAINAGE   AGENTS 


197 


eter  depending  upon  the  size  of  cavity  to  be  drained,  and  this  sur- 
rounded with  rubber  tissue,  leaving  a  portion  of  gauze  at  either  end 
uncovered  (Fig.  154).  This  arrangement  acts  like  a  wick,  the 
end  which  is  buried  in  the  wound  collects  the  exudates,  which  are 
led  along  the  gauze  inclosed  in  the  rubber  tissue  and  discharged 
by  means  of  the  distal  end  into  the  protective  dressing.     In  this 


Fig.  150. — Catgut  Drain  in  situ. 


instance  the  gauze  should  be  moist,  and  the  two  ends  especially 
should  be  quite  soaked  with  salt  solution  or,  in  certain  cases,  with 
antiseptic  solution. 

This  drain  is  the  one  most  generally  used  in  surgery.  It  is 
clean,  easily  handled,  and  effective.  It  may  be  used  in  aseptic  or 
infected  wounds.  In  the  latter  instance,  however,  it  must  be 
changed  frequently,  as  the  gauze  very  soon  becomes  the  nahr- 
boden  for  bacteria.  However,  the  fact  that  its  replacement  is 
attended  with  so  little  disturbance  makes  this  fact  only  slightly 
objectionable.     Fig.  155  shows  the  "  cigarette  drain  "  in  situ. 

The  arrangement  of  silk-worm  gut,  catgut,  rubber  tissue,  and 
the  cigarette  drains  is  shown  in  Figs.    148  to   155.      The  silk- 


198 


DRAINAGE   OF   OPERATIVE  WOUNDS 


worm  gut  and  catgut  drain  will  be  seen  to  extend  to  a  considerable 

extent  beyond  the  margins  of  the  wound.     This  favors  capillarity. 

The  silk-worm  gut  drain  allows  of  removal  of  a  strand  or  two 


Fig.  151. 


-Glass   Jar   for   Storing   Sterile   Rubber  Tissue  in 
Corrosive  Sublimate  Solution  1  in  1,000. 


at  a  time  as  the  discharge  from  the  wound  becomes  less.  The  cat- 
gut drain,  as  already  stated,  need  not  be  removed,  being  absorbed. 
However,  there  is  some  irregularity  with  regard  to  the  time  re- 


Fig.  152. — Rubber  Tissue  Rolled  on  Itself  for  Drainage  Purposes. 

quired  for  absorption  of  this  agent,   and  at  times  these  drains 
also  require  removal. 

The  cigarette  drain  should  protrude  slightly  from  the  wound, 
the  gauze  being,  of  course,  made  to  extend  beyond  the  rubber  tissue 
envelop.     The  rubber  tissue  drain  protrudes  to  the  extent  shown. 


DRAINAGE   AGENTS 


199 


Rubber  tissue  drains  do  not  act  by  capillarity  and  simply  provide 
an  avenue  of  egress  for  the  discharges.  Logically,  rubber  tissue 
drains  should  be  employed  only  at  dependent  portions  of  the  wound. 


Fig.  153. — Rubber  Tissue  Drain  in  situ. 


Their  most  useful  field  is  that  of  drainage  of  uninfected  wounds 
where  much  trauma  has  been  necessary.     They  occupy  a  position, 


Fig.  154. — Cigarette  Drain. 


as  regards  efficiency,  about  between  cigarette  drains  and  silk-worm 
gut  drains. 

The  indication  for  their  use  may  be  illustrated  as  follows. 
Given  a  celiotomy  for  infection  in  the  female  pelvis  with  many 
adhesions  and  considerable  trauma  to  the  abdominal  wound,  the 
outcome  of  severe  manipulations  during  the  operation,  it  not  un- 


200 


DRAINAGE  OF  OPERATIVE  WOUNDS 


commonly  occurs  that  the  sheath  of  the  rectus  sloughs.  In  this 
instance  rubber  tissue  drainage  under  the  skin  is  a  wise  measure. 
Given,  on  the  other  hand,  a  case  of  neoplasm  of  the  neck  which 
requires  much  dissection  without  any  particular  mauling  of  the 
tissues,  the  employment  of  silk-worm  gut  drainage  for  a  few  days 
subsequent  to  the  operation  is  sufficient  to  meet  the  indications. 
Rubber  tube  drainage,  except  in  rare  instances  such  as  em- 


Fig.  155. — Cigarette  Drain  in  situ. 

pyema,  or  suppurative  osteomyelitis,  need  not  be  maintained  for 
more  than  three  or  four  days.  It  may  then  be  replaced  by  rubber 
tissue  drainage,  and  ultimately  by  a  silk-worm  gut  drain,  and  this 
removed  strand  by  strand  as  indicated  by  the  amount  and  char- 
acter of  the  discharge  from  the  wound.  Prolonged  maintenance 
of  drainage  is  prejudicial  to  repair,  and  in  no  instance  should 
drainage  agents  be  caused  to  make  undue  pressure  on  the  tissues. 


CHAPTER    IX 
SUTURING  OF  OPERATIVE  WOUNDS 

Needles — Needle  holders — Suturing  of    wounds:    The   continuous   suture;    the 
interrupted  suture;    harelip   pins. 


The  object  of  suturing  wounds  is  to  hold  tissues  in  apposition 
until  repair  takes  place.  Forcible  apposition  of  wound  surfaces 
attains  no  desirable  object,  and  is  objectionable  for  the  reason  that 
normal  interchange  of  nutritive  elements  is  interfered  with,  caus- 


Fig.  156. — Suture  Properly  Tied.     Knot  drawn  to  one  side. 

ing  pressure  necrosis,  and  unnecessary  deformation  of  needle 
punctures  is  provoked,  resulting  in  unsightly  scaring.  Wounds 
subjected  to  pressure  from  sutures  are  liable  to  infection  for  the 
reasons  stated. 

201 


202 


SUTURING   OF   OPERATIVE   WOUNDS 


A  properly  introduced  suture  causes  the  edges  of  the  wound 
to  lie  in  gentle  contact  with  each  other  (Fig.  156).  A  skin  sut- 
ure should  not  produce  wrinkling  within  its  confines.  As  a  gen- 
eral rule,  a  suture  which  wrinkles  the  skin  is  too  tightly  drawn 
(Fig.  157).     It  may  be  said  that  wounds  should  be  held  in  appo- 


Fig.  157. — Suture  Improperly  Tied,  Causing  Strangulation  of  the  Tissues. 


sition  without  tension.  If  approximation  without  tension  is  not 
feasible,  relaxation  sutures  should  be  introduced  to  obviate  the 
tension  of  the  tissues  immediately  contiguous  to  the  wound. 
(Figs.  179,  180,  181,  182.) 

When  sutures  are  introduced  in  the  faulty  manner  shown  in 
Fig.  157,  the  skin  is  puckered,  the  outer  surface  of  the  skin  is 
brought  in  contact,  and  union  of  the  edges  of  the  wound  does  not 
take  place.  In  another  class  of  cases  the  skin  is  turned  outward 
with  the  same  result.  In  either  instance  the  surgeon  is  confronted 
with  a  failure  of  accurate  healing,  and  the  ultimate  outcome  is  a 
faulty  cosmetic  result.  This  may  not  be  a  matter  of  great  import 
in  instances  when  the  operation  involves  the  unexposed  portions 
of  the  body,  but  is  of  great  significance  when  the  face  is  attacked. 


NEEDLES 


203 


In  any  event  it  means  somewhat  protracted  healing,  which  is  un- 
necessary and  should  be  avoided. 


NEEDLES 

The  suturing  of  wounds  is  accomplished  by  means  of  needles 
of  various  kinds.  Much  has  been  written  with  regard  to  the  em- 
ployment of  various  kinds  of  needles  in  the  several  parts,  organs, 
and  tissues  of  the  body.  An  extended  consideration  of  the  rela- 
tive value  of  the  several  kinds  of  needles  to  be  used  in  given  parts 
does  not  properly  belong  here.  It  is,  however,  proper  to  state,  in 
a  general  way,  that  needles  which  puncture  the  tissues  are  best 
used  in  the  skin  and  superficial  parts,  while  needles  which  sepa- 
rate the  tissues  are  of  most  service  in  apposing  muscles  and  serous 
membranes. 

The  diameter  of  the  needle  to  be  used  for  a  certain  repair  de- 
pends upon  the  thickness  of  the  suture  it  is  intended  to  carry 
through  the  tissues,  and  the  latter  depends  upon  the  amount  of 
tension  to  be  overcome  and  the  length  of  time,  immobilization, 
and  apposition  of  the  divided  parts  is  to  be  maintained. 

Needles  intended  to  puncture  the  tissues  are  usually  made 


Fig.  158. — Straight 
Surgical  Needle 
with  Cutting 
Edges.     (Bryant.) 


Fig.  159.  — Half- 
Curved  Surgical 
Needle  with 
Cutting  Edges. 
(Bryant.) 


Fig.  160.— Full- 
Curved  Surgical 
Needle,  with 
Cutting  Edges. 
(Bryant.) 


with  cutting  edges,  and  these  are  made  either  straight  (Fig.  158), 
half  curved  (Fig.  159),  or  full  curved  (Fig.  160).  In  suturing 
skin  where  cosmetic  effect  is  to  be  considered,  the  flat  Hagedorn 


204 


SUTURING   OF   OPERATIVE  WOUNDS 


needle  is  universally  employed.  These  needles  are  readily  ob- 
tained in  varying  forms  from  the  straight  variety  (Fig.  161), 
the  half  curved  (Fig.  162),  and  the  full  curved  (Fig.  163). 

A 


Fig.  161. — Straight 
Hagedorn  Needle. 
{Bryant.) 


Fig.  162.— Half- 
Curved  Hagedorn 
Needle.  {Bryant.) 


Fig.  163.— Full- 
Curved  Hagedorn 
Needle.  {Bryant.) 


%\ 


The  puncture  made  by  the  surgical  needle  causes  trauma,  as 
shown  in  Fig.  164  c,  d,  i.e.,  the  stitch  hole  is  horizontal  to  the 
wound,  as  would  be  expected  from  the  nature  of  the  needle,  which 
cuts  its  way  through  the  tissues,  as  indicated  in  Fig.  164,  d.    When 
the  suture  is  tied,  the  conformation  of  the  stitch  hole  is  as  indi- 
cated in  the  same  illustration. 
When     ultimate     repair     takes 
place  the  residual  scar  is  likely 
to      be      offensively     manifest. 
When  the  Hagedorn  needle  of 
either  conformation  is  used  the 
stitch   hole   corresponds   to  the 
illustration     shown      (Fig. 
164,  b).     When,  now,  the  su- 
ture  is  tied,   there  is   a   slight 
elongation  of  this  hole  without  as  great  a  degree  of  solution  of 
continuity  of  tissue  (Fig.  164,  a).     This  would  argue  for  the  use 
of  the  Hagedorn  needle  in  all  situations  in  which  cosmetic  effect 
is  a  factor. 

The  round  needle  employed  for  approximation  of  peritoneal 
surfaces  may  also  be  obtained  in  varying  sizes  and  of  varying  de- 
grees of  curvature,  from  the  ordinary  cambric  needle  to  the  heavy, 


Fig.  164. — Needle  Wounds.     (Bryant.) 


NEEDLES 


205 


curved  kind  used  for  repair  of  the  broad  ligament  (Fig.  165). 
Beyond  this,  many  forms  and  kinds  of  needles  are  obtainable,  an 
extended  list  of  which  will  be 
found  in  the  catalogues  of  all  in- 
strument manufacturers.  The 
general  rule  here  offered  is  well 
borne  in  mind,  however,  and  may 
be  regarded  as  a  guide  in  selecting 
an  assortment  of  needles  intended 
to  meet  the  requirements  of  opera- 
tions on  various  parts  of  the  body. 

When  sutures  are  to  be  deeply 
placed  a  long  needle  with  a  handle 
is  frequently  employed.  Of  this 
instrument  many  kinds  are  upon 
the  market.  They  possess  the  ad- 
vantage of  puncturing  the  tissues 
deejjly  and  accurately.  A  few 
of  the  sort  most  commonly  used   are   shown   in   Figs.    166-168. 

Fig.  166  shows  the  Coe  needle,  which  is  largely  employed  to 
insert  interrupted  sutures  into  the  abdominal  wall  following  celi- 


Fig.  165. — Round  Needle  for  Ap- 
proximating Serous  Surfaces 
and  Muscular  Fiber.  On  the 
right,  cambric  needle  for  intestinal 
suture.      (Kelly.) 


Fig.  166. — Coe's  Needle  with  Handle. 


otomy.  The  needle  is  first  introduced  and  the  suture  threaded 
with  the  eye  protruding  distally.  The  suture  is  then  drawn 
through  the  tissues   in  the  reverse  direction.      The  difficulty  in 


Fig.  167. — Hagedorn  Needle  with  Gentile  Handle. 

threading  the  suture  through  the  eye,  which  is  of  course  filled 
with  blood,  makes  this  needle  less  useful  than  if  such  were  not  the 
case.  In  instances  in  which  the  abdomen  is  very  fat  the  instru- 
ment will  be  found  of  service. 

Fig.  167  shows  a  needle  devised  to  overcome  the  difficulty  with 


206  SUTURING   OF  OPERATIVE   WOUNDS 

respect  to  threading  the  suture  mentioned,  by  notching  the  side 
of  the  instrument  near  its  cutting  end.  This  renders  insertion  of 
the  suture  more  easy.  However,  not  infrequently  the  skin  is 
caught  in  the  notch  and  considerable  difficulty  is  experienced  in 
placing  the  suture. 

Fig.  168  shows  a  needle  used  for  placing  sutures  in  operations 
for  the  relief  of  hernia.  The  needle  is  bent  at  right  angles  to  the 
shaft  and  is  furnished  with  a  roomy  eye  for  the  purpose  of  carrying 


Fig.  168. — De  Garmo's  Femoral  Needle. 


kangaroo  tendon  sutures,  which  are  largely  used  for  the  purpose. 
The  same  objection  with  respect  to  the  difficulties  in  threading 
the  sutures  mentioned  is  applicable  in  this  connection.  It  has, 
however,  a  useful  place  in  the  class  of  cases  for  which  it  is  intended. 
These  needles  are  commonly  used  in  placing  relaxation  sutures 
and  in  suturing  the  skin  of  the  abdominal  wall  and  after  extirpa- 
tion of  the  mammary  gland  in  patients  who  have  a  large  quantity 
of  subcutaneous  fat.  However,  they  do  not  form  an  essential  ac- 
quisition to  the  surgeon's  armatarium  and  may  be  properly  re- 
garded as  refinements,  and,  after  all,  are  of  questionable  utility. 
As  a  general  rule,  it  may  be  stated  that  each  puncture  of  the  skin 
increases  the  liability  of  infection,  and  as  the  needles  with  a  handle 
must  of  necessity  first  transfix  the  skin  and  then  draw  the  suture 
through  in  the  opposite  direction,  a  single  manipulation  as  obtains 
with  the  threaded  needle  is  the  more  desirable  manipulation.  In- 
deed, when  introducing  the  interrupted  suture,  the  writer  employs 
several  needles  in  repairing  an  extensive  wound,  on  the  theory  that 
the  repeated  entrance  of  the  skin  with  the  one  needle  is  more  likely 
to  result  in  skin  infection  than  if  a  fresh  needle  be  used  after 
several  sutures  have  been  placed  in  situ.  More  especially  is  this 
the  case  in  repair  of  the  intestine,  where  each  suture  is  introduced 
with  a  different  needle,  with  the  view  of  forestalling  the  convey- 
ance of  infection  by  means  of  a  needle  and  suture  which  may  in- 
advertently have  punctured  the  lumen  of  the  gut. 


NEEDLE    HOLDERS 


207 


NEEDLE   HOLDERS 

Needle  holders  are  universally  employed  for  the  introduction 
of  sutures.  Here  again  an  extended  discussion  is  out  of  place. 
However,  it  may  be  said  that  the  instrument  should  be  used  for 
the  purpose  in  place  of  the  fingers  whenever  practicable.  Instru- 
ments are  always  less  liable  to  be  the  habitat  of  infective  bacteria 
than  the  fingers  for  obvious  reasons,  and  the  manipulations  neces- 
sary to  the  introduction  of  sutures,  coining  as  they  do  at  the  end 
of  an  operation,  find  the  fingers  of  the  operator  frequently  con- 


'  Fig.  169. — Hartley-Markoe  Needle  Holder.     {Bryant.) 

taminated  as  the  outcome  of  the  operative  procedure.  Indeed,  it 
is  the  habit  of  the  writer  to  turn  the  closure  of  the  wound  over  to 
an  assistant  whenever  this  is  a  consideration  worthy  of  being  taken 
into  account  from  the  nature  of  the  operation. 

As  in  the  case  of  needles  and  suture  carriers,  innumerable 
models  of  needle  holders  are  obtainable  in  the  market,  each  one 
of  which  bears  a  name  of  an  inventor.  As  a  general  proposition, 
the  life  of  utility  of  a  needle  holder  depends  upon  the  resistance 


Fig.  170. — Sand's  Needle  Holder.     (Bryant.) 

of  its  biting  surfaces.  As  this  depends  upon  the  elasticity  of  the 
metal  surface,  no  needle  holder  will  be  found  serviceable  in  per- 
petuity. It  is,  therefore,  well  for  the  surgeon  to  have  within  easy 
reach  tAvo  needle  holders  at  all  times,  as  the  limit  of  elasticity  of 
the  metal  may  be  reached  at  any  time.  The  disregard  of  this  pre- 
caution is  often  responsible  for  a  display  of  irritability  on  part 
of  the  operator  which,  being  enhanced  by  the  exhausting  effects 
of  a  prolonged  operation,  at  times  culminates  in  the  offending  in- 


208 


SUTURING   OF   OPERATIVE  WOUNDS 


strument  being  thrown  violently  upon  the  floor,  and  if  there  be  no 
second  instrument  at  hand,  the  rest  of  the  suturing  must  be  accom- 
plished with  the  fingers.      This  being  an  undignified  and  unde- 


Fig.  171. — Luer's  Needle  Holder.     (Bryant.) 

sirable  outcome,  the  precaution  mentioned  is  best  borne  in  mind. 

A  number  of  needle  holders  are  depicted  in  Figs.  169  to  173. 

Each  has  its  advocates,  but,  no  doubt,  acquaintance  with  the  mech- 


Fig.  172. — Halsted-Leur  Needle  Holder.     (Bryant.) 

anism  of  any  of  them  will  develop  efficiency  in  its  use.  Fig.  173 
shows  a  holder  furnished  at  its  biting  surface  with  a  piece  of  soft 
metal  which  will  conform  to  the  size  of  most  any  needle.     It  is  to 


Fig.  173. — Ermold  Needle  Holder. 


be  remembered  that  this  piece  of  metal  ultimately  undergoes  per- 
manent deformation  for  the  reason  already  stated,  and  that  this 
should  be  frequently  replaced.     In  addition,  the  lock  at  the  ter- 


NEEDLE  HOLDERS 


209 


mination  of  the  handles  closes  at  one  bite  and  releases  at  the  next, 
which  makes  this  an  exceedingly  comfortable  instrument  to  work 
with,  especially  when  working  in  deep  cavities. 

Fig.  174  shows  a  needle  holder  which  Kelly  uses  to  hold  curved 


J 


Fig.  174. — Kelly  Needle  Holder 
for  Round  Needles.     (Kelly.) 


Fig.  175. — Needle  Holder  Showing  Method 
of  Grasping  Round  Needle.     (Kelly.) 


needles.  The  handles  are  heavy  and  serrated,  permitting  of  a  firm 
grasp,  and  the  ends  tapering,  which  permits  of  working  in  deep 
cavities.      The   biting  surfaces   are   of  soft   copper,    allowing  of 


210 


SUTURING   OF  OPERATIVE  WOUNDS 


adaptability  with  respect  to  the  size  of  needle  employed.  The 
criticism  made  in  connection  with  the  Ermold  needle  holder  re- 
specting permanent  deformation  of  the  soft  metal  applies  here. 
The  lock  is  operated  with  the  thumb  and  is  a  convenient  one.  It 
is  not,  however,  as  readily  handled  as  obtains  with  the  Ermold 
holder. 

Fig.  175  shows  the  manner  of  grasping  the  needle  near  its  eye. 
At  this  point  the  needle  is  usually  of  greatest  strength  and  is  less 


Fig.  176. — Continuous  Suture  Ready  to  be  Tied.     Half-curved  surgical  needle. 

liable  to  break  when  being  manipulated.  On  the  other  hand,  the 
long  lever  distal  to  the  bite  makes  this  manner  of  holding  the  needle 
less  firm  when  being  inserted  into  resisting  tissue,  in  consequence 
of  which  the  needle  rotates  in  the  holder,  giving  it  a  direction  in 
passing  through  the  tissues,  other  than  was  intended.  This  may 
be  overcome  by  grasping  the  needle  nearer  its  middle  when  using 
it  under  the  conditions  mentioned. 


SUTURING   OF  WOUNDS 


211 


SUTURING   OF   WOUNDS 
THE   CONTINUOUS  SUTURE 

The  continuous  suture  is  the  one  most  universally  used  (Fig. 
177).     When  there  is  reasonable  assurance  that  infection  has  not 


Fig.  177. — Continuous  Suture  Completed  and  Tied. 


Fig.  178. — Interrupted  Suture  Properly  Introduced  and  Tied.     Knots 

drawn  to  one  side, 
lu 


Fig.  179. — Relaxation  or  Tension  Sutures.     The  approximation  sutures  are 
improperly  tied.     The  knots  should  be  drawn  to  one  side. 


Fig.  180. — Tension  Sutures  Threaded  on  Buttons  to  Obviate  "Cutting." 
One  suture  ready  to  be  tied,  the  other  tied. 

212 


Fig.  181. — Tension  Sutures  Looped  over  Pledgets  of  Gauze. 


Fig.  182. — Method  of  Introducing  Harelip  Pins  to  Relieve  Tension  in  Wound. 

213 


214 


SUTURING   OF   OPERATIVE   WOUNDS 


occurred  during  the  operation,  it  is  a  most  desirable  form  of  suture, 
as  it  permits  of  accurate  apposition  of  the  edges  of  the  wound,  and 
if  it  be  necessary  to  remove  it,  the  patient  is  subjected  to  a  mini- 
mum of  annoyance  in  accomplishment  of  the  act,  as  it  needs  be 
only  loosened  at  its  distal  ends  and  withdrawn.  This,  of  course, 
applies  only  when  the  suture  material  is  of  the  non-absorbable 
variety.     Fig.   176  shows  the  continuous  suture  introduced  and 


Fig.  183. — Suture  Material  Looped  Over  Harelip  Pins,  Drawing  Edges 
of  Wound  Together. 


ready  to  be  tied.  The  needle  is  the  one-half  curved  surgical  kind, 
usually  used  for  the  purpose.  Fig.  177  shows  the  suture  finished, 
and  the  ends  cut  short. 

The  usual  rule  is  to  employ  this  class  of  suture  in  the  deep 
tissues  and  not  in  the  skin,  for  the  reason  that  abscess  in  the  suture 
punctures  is  exceedingly  liable  to  happen  in  the  latter  situation 


SUTURING   OF    WOUNDS 


215 


despite  all  precautions,  and  the  continuous  suture  forms  a  path 
along  which  infection  may  easily  travel.  In  the  illustrations  the 
suture  is  shown  introduced  into  the  skin  for  the  sake  of  clearness. 


THE   INTERRUPTED   SUTURE 


The  interrupted  suture  is  shown  in  Fig.  178.     Care  should 
be  taken  not  to  draw  the  edges  of  the  wound  too  tightly  together 


Fig.  184. — Ends  of  Harelip  Pins  Cut  Off. 


(Fig.  157),  but  to  simply  bring  them  into  apposition  (Fig.  156), 
for  the  reasons  already  stated.  If  there  be  much  tension  in  the 
wound,  relaxation  sutures  are  introduced.  These  may  consist  of 
simple  deep  sutures  introduced  in  the  manner  shown  in  Fig.  179, 
or  threaded  on  buttons  (Fig.  180),  or  looped  over  pledgets  of  gauze 


216  SUTURING   OF   OPERATIVE   WOUNDS 

(Fig.   181),  with  the  view  of  obviating  undue  pressure  on  the 
tissues. 

HARELIP   PINS 

Some  surgeons  prefer  to  supplement  the  approximation  sut- 
ures with  the  introduction  of  harelip  pins.  These  pins  are  intro- 
duced quite  widely  from  the  edges  of  the  wound  (Fig.  182),  and 
heavy  suture  material  is  looped  over  the  protruding  ends  (Fig. 
183),  bringing  the  edges  of  the  wound  together.  The  ends  of  the 
pins  are  at  last  cut  off  as  in  the  manner  shown  in  Fig  184. 

Harelip  pins  are  likely  to  cut  into  the  soft  tissues,  especially 
if  there  be  much  tension,  the  outcome  of  the  effort  to  approximate 
the  edges  of  the  wound.  This  makes  the  employment  of  the  pins 
less  serviceable  than  the  button  suture  or  the  loops  padded  with 
gauze  pledgets. 


CHAPTEK    X 
THE   DRESSING  OF    OPERATIVE    WOUNDS 

Antiseptic  powders — Iodoform  and  its  modifications — Application  of  powder 
— The  protective  dressing — Gauze  for  dressings:  Medicated  gauze;  sterile 
gauze;  the  combined  dressing. 

ANTISEPTIC   POWDERS 

After  approximation  of  the  edges  of  the  wound,  it  is  customary 
to  apply  to  it  and  the  surrounding  surfaces  some  antiseptic  pow- 
der. This  is,  however,  not  so  universally  done  at  this  time  as 
obtained  formerly.  The  use  of  certain  agents  seems  to  go  in  cycles. 
At  times  an  agent  which  has  been  quite  universally  employed  by 
every  one  falls  into  disuse,  to  be,  perhaps,  again  exploited  and  to 
have  as  wide  a  vogue  as  ever. 

The  fact  is,  that  the  use  of  antiseptic  dusting  powders  has  a 
rationale  which  has  its  justification  in  chemistry  and  bacteriology 
as  applied  to  their  employment  in  this  connection.  Before  the 
employment  of  asepsis,  dusting  powders  and  certain  remedial 
agents  were  applied  to  wounds  with  the  idea  of  stimulating  repair. 
A  more  accurate  knowledge  of  the  genesis  of  cells  following  sur- 
gical trauma  has  shown  that  the  real  usefulness  of  antiseptics  lies 
in  their  power  to  destroy  bacteria,  although  no  one  could  deny  that 
the  application  of  a  sterile  mercury  ointment  to  a  wound  in  the 
person  of  a  syphilitic  who  has  been  subjected  to  operation  has  a 
beneficial  effect,  and  that  the  introduction  of  iodoform  into  the 
superficial  wound  of  approach  in  removal  of  tuberculous  glands  is 
a  scientific  and  rational  indulgence.  Then,  too,  if  there  be  in- 
fection in  the  operative  field,  it  is  more  reasonable  to  expect  benefit 
from  antiseptic  lavage  than  from  mechanical  cleansing,  especially 
with  saline  solution.  For  if  there  is  a  medium  which  makes  a 
favorable  culture  field  for  bacteria,  it  is  a  normal  salt  solution. 
This  is  well  illustrated  by  the  fact  that  salt  solution  is  used  where 

217 


218  THE   DRESSING  OF   OPERATIVE  WOUNDS 

tissues  are  to  be  guarded  against  interference  with  nutrition,  such 
as  in  skin  grafting. 

Two  factors  enter  into  the  immediate  after-treatment  of  oper- 
ative wounds.  One  is  the  prevention  of  contact  of  infective  mate- 
rial with  the  wound,  and  the  other  the  destruction  of  bacteria  which 
may  be  in  immediate  contact  with  the  wound  and  which  will 
cause  infection  if  the  conditions  are  favorable. 

It  is,  as  already  shown,  quite  impossible  to  sterilize  the  skin 
absolutely.  Taking  the  problem  up  from  that  standpoint,  nothing 
could  be  more  favorable  to  the  invasion  of  the  wound  by  infective 
bacteria  than  to  have  it  and  the  contiguous  skin  covered  with  a 
thin  layer  of  serum  and  coagulated  bloo(,l.  Oozing  is  never  so 
absolutely  arrested  as  to  prevent  this  contingency.  Even  though 
primary  union  is  obtained  in  a  given  instance,  the  skin  near  the 
wound  and  the  area  of  union  is  always  found  covered  with  this 
coating  when  the  dressing  is  removed.  The  fact  that  serum  is  so 
largely  used  as  a  culture  medium  in  the  bacteriological  laboratories 
would  suggest  that  the  statement  just  made  had  some  foundation 
in  fact. 

Assuming  that  the  hair  follicles,  sebaceous  glands,  and  sudo- 
riparous glands  are  the  habitat  of  bacteria  and  that  the  skin  im- 
mediately contiguous  to  the  wound  is  coated  with  a  culture  medium 
favorable  to  their  growth  and  development,  it  is  easy  to  see  how 
infection  would  find  its  way  to  the  wound,  and,  indeed,  the  much 
discussed  stitch  abscess  may  be  attributed  in  a  certain  number  of 
instances  to  this  cause.  It  is,  of  course,  not  to  be  forgotten  that 
division  of  the  hair  follicles  by  the  puncturing  needle  is  an  impor- 
tant causative  factor  in  this  connection,  yet  the  one  mentioned 
should  not  be  disregarded. 

Indeed,  the  growth  of  bacteria  always  requires  a  favorable  cul- 
ture medium.  It  is  the  experience  of  all  surgeons  that  stitch  ab- 
scess does  not  occur  as  frequently  when  silk-worm  gut  is  used  in 
approximating  the  wound  as  when  catgut  is  employed  for  the  pur- 
pose. This  does  not  by  any  means  permit  of  the  conclusion  that 
the  catgut  was  not  sterile.  It  may  simply  mean  that  catgut  is  a 
far  more  favorable  culture  medium  for  bacteria  than  is  the  smooth, 
hard  silk-worm  gut.  The  fact  that  catgut  undergoes  a  physical 
change  while  in  situ  may,  too,  contribute  to  this  difference,  i.e., 
the  gradual  absorption  of  the  catgut  probably  changes   it   into 


IODOFORM  AND   ITS   MODIFICATIONS  219 

a  more  favorable  culture  medium  for  bacteria,  an  assumption 
supported  by  the  fact  that  infection  in  the  stitch  holes  occurs 
not  infrequently  on  the  eighth,  and  even  as  late  as  the  twen- 
tieth day. 

Assuming  a  wound  approximated  by  a  continuous  catgut  sut- 
ure, the  line  of  which,  together  with  the  immediately  contiguous 
skin,  is  coated  with  a  layer  of  wound  secretion,  no  great  stretch 
of  the  imagination  is  required  to  see  a  colony  of  bacteria  invading 
the  crust,  either  from  a  neighboring  hair  follicle  or  from  one  of 
the  perforations  made  -by  the  needle,  growing  rapidly,  and  extend- 
ing along  the  entire  suture  line.  These  are  conditions  exceedingly 
favorable  to  infection  of  the  superficial  wound  and,  indeed,  the 
outcome  is  of  sufficient  frequency  to  be  a  familiar  picture  to  the 
surgeon,  and  more  especially  to  the  practitioner  who  carries  out 
the  after-treatment  and  is,  at  the  end  of  a  week,  confronted  with 
a  state  of  affairs  for  which  he  is  not  infrequently  made  respon- 
sible by  the  patient  and,  too,  greeted  at  times  with  certain  sar- 
castic remarks  from  the  .operator. 

In  contrast  to  this,  it  is  also  easy  to  see  that,  given  a  wound 
closed  by  interrupted  sutures  of  silk-worm  gut,  the  edges  and  sur- 
rounding skin  of  which  is  covered  with  an  antiseptic  which  im- 
pregnates the  secretions,  infection  is  not  so  liable  to  occur.  And, 
indeed,  this  is  quite  the  fact.  At  times  an  infection  of  a  single 
stitch  will  occur,  and  be  it  said  that  this  may  be  the  case  despite 
all  precautions.  However,  infection  of  the  entire  wound  is  cer- 
tainly less  apt  to  obtain  if  the  latter  conditions  prevail. 

IODOFORM   AND    ITS   MODIFICATIONS 

An  effort  has  been  made  to  obviate  contamination  of  the 
wound  by  sealing  it  firmly  with  collodion.  This  has  proven  un- 
satisfactory, however,  as  it  retains  the  secretions  from  the  wound 
in  a  confined  place,  does  not  destroy  the  bacteria  in  the  stitch 
holes,  and  infection  occurs.  The  general  surgical  principle  of 
the  confining  of  secretions  applies  here  with  equal  force,  though 
the  quantity  of  secretion  is  very  small.  If,  however,  the  collo- 
dion be  thoroughly  impregnated  with  an  antiseptic,  the  bacteria 
may  be  destroyed.  It  is,  nevertheless,  a  better  principle  to  per- 
mit bacteria   to  exhaust  themselves   in   a  large   antiseptic   area 


220 


THE   DRESSING   OF   OPERATIVE   WOUNDS 


than  to  depend  upon  the  bactericidal  effect  of  small  quantities 
of  antiseptics. 

Iodoform  has  maintained  its  place  in  this  field  of  usefulness. 
It  has  been  shown  to  be  of  itself  less  resistant  to  the  invasion  of 
bacteria  than  is  suggested  by  its  manifestly  beneficial  effect 
clinically  demonstrated.  It  is  probable  that  the  combination  of 
the  agent  with  blood  liberates  free  iodin  upon  which  its  useful- 
ness depends.  The  objectionable  odor  of  iodoform  has  led  to 
many  modifications  in  its  preparation,  of  which  aristol  is  an  ex- 
ample. It  is  probable  that  aristol  is  quite  as  efficacious  as  the 
former,  and  is  free  from  odor.  Iodol,  naphthalan,  and  similar 
preparations  are  largely  used  for  the  purpose,  all  of  which  have 
exponents.  Orthoform,  vioform,  bismuth  and  the  like  are  all  of 
usefulness.     Vioform  is  largely  used  in  Berlin. 


APPLICATION   OF   POWDER 

Care  should  be  taken  to  sterilize  the  agent  before  use,  pro- 
vided heat  will  not  cause  a  chemical  change  rendering  it  inert. 
In  any  case'  the  container  should  be  sterilized  before  the  opera- 
tion. Ordinarily  the  powder  is  applied  to  the 
wound  and  surrounding  parts  with  a  sprinkler 
(Fig.  185).  This  apparatus  is  exceedingly  con- 
venient and  cleanly  if  sterilized  each  time  it  is 
used.  Repeated  use  of  the  sprinkler  without  this 
precaution  is  warned  against. 

A  safe  and  convenient  method  of  use  is  to 
place  the  powder  into  a  sterile  jar,  covered  with 
wide-meshed  gauze.  The  powder  may  then  be 
applied  without  fear  of  causing  contamination. 
About  enough  powder  for  an  operation  may  be 
prepared  from  the  stock  package  for  each  opera- 
tion, and  the  small  quantity  remaining  may  be 
discarded.  Fig.  186  shows  a  jar  prepared  in 
this  way.  The  mixture  of  blood,  serum,  and 
antiseptic  powder  certainly  presents  a  medium 
Fig.  1S5.  —  Anti-     less  favorable  to  the  growth  of  bacteria  than  do 

SEPTIC  POWDEE         ^    secretions    al(me. 

Sprinkler. 

(Bryant.)  Before   applying  the  powder,  the  wound  is 


THE   PROTECTIVE   DRESSING 


221 


washed  with  a  solution  of  corrosive  sublimate  1-1,000,  and  the 
secretions  from  the  wound  together  with  the  solution  are  wiped 
away.  Covering  of  the 
wound  with  inordinate 
quantities  of  powder 
serves  no  useful  pur- 
pose; indeed,  in  the  in- 
stance of  iodoform, 
poisoning  may  occur. 
Of  course  this  is  not 
likely  to  be  the  case  if 
the  iodoform  be  used  on 
a  sutured  wound,  and 
applies  more  largely  to 
its  application  to  ex- 
tensive raw  surfaces. 
•However,  the  possibil- 
ity of  its  occurrence  is 
to  be  remembered. 
Again,  iodoform  at 
times  gives  rise  to  der- 
matitis, and,  indeed, 
some  individuals  posses 
an  idiosyncrasy  in  this 
regard.     The  condition 

disappears  as  soon  as  the  cause  is  removed.  Patients  found  sus- 
ceptible in  this  way  should  be  informed  of  the  conditions  with  the 
view  of  obviating  a  recurrence  of  the  event. 

In  wounds  which  are  drained,  too  liberal  a  use  of  powder 
may  obstruct  drainage,  and  care  should  be  taken  to  avoid  this. 
As  a  general  proposition,  a  moderate  use  of  these  agents  conserves 
the  interests  of  the  patient  better  than  too  liberal  application. 


Fig.  186. 


-Powder  Sprinkler  Used  in  Opera- 
ting Room. 


THE   PROTECTIVE   DRESSING 

The  protective  dressing  is  applied  to  wounds  for  the  purpose 
of  absorbing  discharges  and  to  prevent  the  entrance  of  infect- 
ive agents.  The  immobilization  of  parts  in  order  to  conserve 
repair  is  a  problem  entirely  distinct  from  the  two  propositions 


222 


THE   DRESSING   OF   OPERATIVE  WOUNDS 


stated,  though,  of  course,  the  three  objects  are  attained  simul- 
taneously. 

If  the  theory  offered  with  regard  to  the  susceptibility  of  ex- 
udates from  wounds  being  exceedingly  favorable  to  the  develop- 
ment of  infection  be  true,  there  is  no  question  as  whether  sterile 
dressing  material  or  material  impregnated  with  antiseptics  is  the 
more  rational.  However,  the  contact  with  the  skin  of  material 
saturated  with  wet  antiseptics  is  objectionable  on  the  ground  that 
irritation  is  a  frequent  result.  Indeed,  this  applies  also  to  dry 
antiseptic  dressing  material,  for  the  moisture  from  the  skin,  to- 
gether with  the  secretions  from  the  wound,  cause  the  dry  anti- 
septic to  go  into  solution.     However,  there  is  no  doubt  that  too 


Fig.  187. — Flat  Gauze  Applied  Immediately  to  Wound. 


radical  a  view  of  either  method  is  unnecessary,  and  that  the  best 
method  of  action  is  found  in  a  judicious  application  of  both  prin- 
ciples. 

As  a  general  proposition,  it  may  be  said  that  infected  wounds 
should  be  dressed  with  a  preponderance  of  antiseptic  material 
over  the  unmedicated  dry  material,  while  clean  wounds  require 
less  employment  of  the  antiseptic  dressings.  Taking  the  invasion 
of  the  dressing  by  bacteria  from  the  skin  in  one  direction  (out- 
ward), and  the  assault  of  infective  material  from  the  other  (in- 
ward), it  would  seem  fair  to  assume  that  the  point  at  which  these 
two  will  meet  depends  upon  the  distance  necessary  to  be  traveled 
by  each,  and  the  character  of  the  medium  they  have  to  penetrate. 
Copious  discharges  from  wounds  which  entirely  saturate  the  pro- 


GAUZE  FOR   DRESSINGS 


223 


tective  dressing  constitute  an  easy  avenue  of  approach  in  either 
direction,  for  obvious  reasons.  The  mechanical  hindrance  to  the 
entrance  of  bacteria  is  best  subserved  by  cotton. 

It  would  seem  rational  to  place  in  immediate  contact  with  the 
wound  a  layer  of  dry  gauze  which  is  sterilized  by  heat  only.  This 
prevents  contact  with  medicated  dressing  more  externally  situ- 
ated, and  obviates  the  danger  of  irritation  to  the  skin.  This  is 
best  applied  in  several  layers  folded  flat  (Fig.  187).  The  secre- 
tions from  the  wound  soon  saturate  this  layer  of  gauze,  and  the 
next  layer  of  gauze  may  be  saturated  with  an  antiseptic  and 
dried  with  heat.  Theoretically,  bacteria  which  may  invade  this 
layer  should  be  destroyed  by  coming  in  contact  with  an  antiseptic 


Fig.  188. — Fluffed  Gauze  Placed  Over  Flat  Gauze  Shown  in  Fig.  187. 

solution  of  which  they  themselves  form  the  solvent.  However,  if 
the  case  be  already  infected  this  layer  may  be  moist  at  the  time  of 
application,  and  thus  more  readily  take  up  the  secretions. 


GAUZE   FOR   DRESSINGS 

Gauze  for  dressings  consists  of  cheesecloth  of  varying  num- 
ber of  strands  per  square  inch.  The  closer  the  mesh  the  slower 
will  absorption  of  fluids  take  place ;  on  the  other  hand,  obviously, 
the  closer  the  mesh  the  more  fluid  will  the  gauze  take  up.  As  a 
general  rule,  gauze  with  24  x  32  threads  per  square  inch  will  be 
found  efficacious  for  all  practical  purposes. 

This  layer  of  gauze  should  be  applied  "fluffed"  (Fig.  188). 


224 


THE   DRESSING  OF   OPERATIVE  WOUNDS 


Thus  the  irregularities  in  outline  of  the  part  are  equalized  when 
the  final  bandaging  is  done  and  a  smooth  surface  is  presented. 
This  layer  of  gauze  may  be  simple  sterile  gauze  as  is  used  by  a 
large  number  of  surgeons.  However,  the  considerations  men- 
tioned are  worthy  of  taking  into  account  in  determining  the  ques- 
tion of  medicated  gauze.  The  preparation  of  iodoform  gauze 
has  already  been  described  (page  76). 

Gauze  is  prepared  by  immersing  cheesecloth  of  the  desired 
number  of  threads  to  the  square  inch  in  cold  water  for  twelve 
hours,  with  the  view  of  dissolving  the  starch.  It  is  then  boiled 
for  several  hours,  dried,  and  cut  into  various  sizes  determined  by 
the  purpose  for  which  it  is  to  be  employed.  It  is  then  sterilized 
under  pressure,  as  already  described  (page  62).  The  impregna- 
tion of  the  gauze,  with  antiseptics  is  accomplished  by  immersing 
the  gauze,  after  boiling,  in  a  solution  containing  the  desired  anti- 
septic and,  after  drying  again,  sterilizing  under  pressure.  The 
antiseptics  most  commonly  used  for  the  purpose  are  carbolic  acid 
1  in  20,  corrosive  sublimate  1  in  1,000,  mercuric  cyanid  1  in 
1,000,  and  the  iodoform  gauze  mentioned. 


Corrosive  sublimate  gauze  is  made 

as  follows : 

Strength. 

1  in  1,000 

1  in  500 

1  in  400 

Absorbent  Cotton  (Dry) 

Corrosive  Sublimate  Sol.  1-1000 
Water  (Sterile)  q.s.  ad 

13    oz.(10yds.) 
12J  oz. 
32    oz. 

13  oz.  (10  yds.) 
25  oz. 
32  oz. 

13  oz.  (10  yds.) 

31  oz. 

32  oz. 

If  facilities  for  sterilization  under  pressure  be  not  available  there 
can  be  no  doubt  that  immersion  in  antiseptic  solutions  is  in- 
dicated. 

Gauze,  both  sterile  and  medicated,  is  put  up  in  convenient 
packages  by  the  trade,  and  if  facilities  for  sterilization  be  not 
convenient,  these  preparations  will  be  found  exceedingly  useful. 

Where  elaborate  dressing  is  necessary  it  is  well  to  use  gauze 
folded  into  a  long  strip  about  four  inches  in  width.  This  is  ap- 
plied to  the  part  in  much  the  same  way  as  a  bandage  (Fig.  189). 
Its  removal,  if  saturated  with  secretions,  is,  however,  attended 
with  more  disturbance  to  the  patient  than  the  "  fluffed  "  gauze, 
which  permits  of  ready  saturation  and  piecemeal  removal  when 
the  wound  is  redressed. 


GAUZE   FOR   DRESSINGS 


225 


Cotton  for  the  protective  dressing  has  many  advantages  over 
the  fluffed  or  roll  gauze,  and  is  applied  in  the  vast  majority  of 
instances.      It  interferes  mechanically  with  the  entrance  of  bac- 


Fig.  189. — Roll  Gauze  Applied  Over  Fluffed  Gauze  Shown  in  Fig.  188. 

teria,  but  is  very  readily  saturated  with  secretions  and,  for  this 
reason,  is  not  as  serviceable  used  next  the  wound  as  is  the  gauze. 
Absorbent  cotton  is  readily  obtained  in  the  shops,  and  if  it  be  used 
supplementary  to  gauze,  need  not  be  medicated,  though  in  this 


Fig.  190. — Combined  Dressing  Applied  Over  Roll  Gauze  Shown  in  Fig.  189. 


instance  there  is  no  objection  to  using  it  medicated  if  there  be 
especial  indication  for  its  use.  It  has,  however,  a  tendency  to 
"  ball  "  when  applied,  and  is  best  employed  in  the  form  of  com- 


226  THE   DRESSING  OF   OPERATIVE  WOUNDS 

bined  dressing  (page  77),  which  consists  of  a  layer  of  cotton 
placed  between  two  pieces  of  gauze.  This  is  a  very  convenient 
dressing,  and  when  applied  presents  a  smooth  surface  which  is 
easily  held  in  place  (Fig.  190)  with  several  strips  of  adhesive 
plaster  over  which  the  retaining  bandage  is  applied.  With  this 
arrangement  of  the  protective  dressing  it  is  believed  that  the 
bacteria  in  the  parts  surrounding  the  wound  are  destroyed,  or  at 
least  their  growth  is  inhibited  and  their  entrance  from  without 
effectually  prevented.  The  attendant  should  err  on  the  side  of 
elaborate  dressing  rather  than  the  reverse.  A  clear  appreciation 
of  the  intent  of  the  dressing  will  explain  this  admonition. 

Oil  silk,  rubber  tissue,  paraffin  paper,  and  other  impermeable 
agents  should,  for  obvious  reasons,  be  applied  between  the  band- 
age and  the  cotton.  Secretion  must  be  permitted  to  invade  the 
dressing  and  not  be  confined  close  to  the  wound.  If  the  imper- 
meable layer  be  placed  too  near  the  wound,  this  will  be  prevented. 
The  agents  mentioned  are  valuable  protection  in  regions  where 
the  dressing  is  apt  to  be  soiled  by  excretions,  such  as  the  urine 
and  feces.  They  are,  too,  very  useful  to  retain  moisture  if,  for 
any  reason,  the  dressing  needs  to  be  kept  wet. 

The  illustrations  show  the  various  steps  in  applying  the  pro- 
tective dressing  in  a  case  of  wound  of  the  thigh.  This  site  is 
selected  for  convenience.  It  is,  of  course,  understood  that  the 
method  of  procedure  applies  equally  to  other  situations. 


CHAPTER    XI 

SHOCK  AND  SECONDARY  HEMORRHAGE 
FOLLOWING   OPERATIONS 

Shock  following  operations — Shock  bed — Treatment  of  shock:  hypodermic 
injections;  mechanical  pressure;  transfusion,  the  direct  transfusion  of 
blood,  suture  method  of  blood-vessel  anastomosis,  instruments  and  mate- 
rial, the  operation;  the  cannula  method  of  blood-vessel  anastomosis:  gen- 
eral management  of  a  transfusion;  the  donor;  the  recipient — Infusion — 
Needling   of    artery — Hypodermoclysis — Enteroclysis. 

Secondary  hemorrhage  following  operations:  The  Mikulicz  tampon;  removal 
of  Mikulicz  tampon. 

SHOCK  FOLLOWING  OPERATIONS 

The  two  most  important  causative  factors  in  shock  from  opera- 
tions are  the  extent  of  trauma  and  loss  of  blood.  These  two  fac- 
tors do  not,  however,  bear  any  direct  proportion  to  the  consequent 
manifestations  in  a  given  case.  The  variations  in  this  regard  may 
be  considered  as  belonging  to  that  mysterious  problem  called  life. 
So-called  life  has  been  made  the  subject  of  more  or  less  intricate 
investigation  for  ages.  The  problem  is  more  wisely,  if  not  with 
the  hope  of  elucidation,  turned  over  to  the  clergy.  Certain  it  is 
that  severe  trauma  may  be  attended  with  very  little  shock,  and 
profound  modification  of  the  so-called  vital  forces  may  attend  a 
comparatively  moderate  degree  of  injury.  This,  is  not  quite  so 
indefinite  an  outcome  with  regard  to  loss  of  blood,  though  here, 
too,  the  rule  applies,  if  with  somewhat  less  force.  Comparatively 
slight  loss  of  blood  may  be  attended  with  considerable  shock, 
though  rarely,  indeed,  is  great  loss  of  blood  not  attended  with 
shock,  albeit  this  may  be  more  severe  in  a  given  case  than  appears 
consistent  with  the  quantity  of  the  circulating  fluid  lost.  In  a 
general  way,  it  may  be  said  that  loss  of  blood  rarely  entails  shock 
of  the  same  degree  of  severity  as  occurs  with  severe  trauma,  and 
that  the  former  is  more  rapidly  recovered  from  than  the  latter. 
17  227 


228  SHOCK  AND   SECONDARY   HEMORRHAGE 

Indeed,  persons  who  have  received  severe  injury  die  very  soon 
after  the  infliction  of  the  trauma,  while  shock  from  loss  of  blood 
is  compensated  for  by  a  physiological  modification  of  functions 
which  gives  opportunity  for  compensation,  as  shown  in  cases  of 
division  of  the  common  iliac  artery  with  the  knife,  when  the  fatal 
outcome  is  quite  delayed,  in  contradistinction  to  the  immediate 
fatal  result  of  injury  to  this  vessel  as  the  outcome  of  gunshot 
wound.  In  the  latter  instance  the  impact  of  the  projectile  is  an 
important  factor  in  the  fatal  issue. 

An  extended  discussion  of  the  mechanism  of  shock  does  not 
belong  here.  However,  an  understanding  of  the  problem  is  neces- 
sary in  order  to  comprehend  the  rationale  of  the  treatment  sug- 
gested. For  a  thorough  acquaintance  with  this  exceedingly  im- 
portant factor  in  the  after-treatment  of  operative  cases,  the  reader 
is  referred  to  Crile's  masterful  work,  "  Surgical  Shock." 

Shock  may  be  regarded  as  a  sudden  depression  of  the  vital 
powers  arising,  as  stated  above,  from  trauma  or  loss  of  blood  acting 
on  the  nervous  system,  and  inducing  exhaustion  or  inhibition  of 
the  vasomotor  mechanism.  Shock  from  mental  emotion  need  not 
be  considered  here.  By  overstimulation  of  sensory  nerves  the  vaso- 
motor center  is  exhausted  or  inhibited,  vaso  constrictor  power  is 
lost,  the  arteries  and  capillaries  are  depleted  or  nearly  emptied  of 
blood,  and  the  blood  accumulates  in  the  veins.  The  blood  pressure 
is  lowered,  cardiac  action  is  impaired,  respiration  is  impeded,  and 
quantities  of  dark  colored  blood  collect  in  the  somatic  veins,  but 
more  especially  in  the  veins  of  the  splanchnic  area. 

In  shock  the  abdominal  veins  and,  indeed,  veins  in  other 
parts  of  the  body  are  distended,  there  is  an  insufficiency  of  blood 
in  the  arteries,  and  a  lessened  amount  of  blood  reaches  the  heart 
and  the  vital  centers  of  the  central  nervous  system.  This  means 
that,  while  the  total  quantity  of  blood  in  the  body  may  not  be 
reduced,  as  obtains  in  cases  of  shock  without  loss  of  blood,  suffi- 
cient blood  is  not  circulating  to  maintain  the  functions  of  the 
vital  centers. 

Collapse  is  a  term  used  to  designate  a  severe  condition  of 
shock,  and  is  employed  by  some  writers  as  a  name  for  a  condition 
of  shock  produced  by  mental  disturbance  rather  than  by  physical 
injury.  Crile  regards  collapse  as  an  inhibition  of  the  vasomotor 
centers  and  shock  as  the  outcome  of  exhaustion  of  these  centers. 


SHOCK  BED  229 

This  conception  is,  however,  not  accepted  by  all  writers.  Shock 
and  collapse  may  co-exist.  Indeed,  it  may  be  said  that  if  any  dif- 
ference exist  between  shock  and  collapse  it  is  only  as  regards  de- 
gree. Taking  a  comprehensive  view  of  the  rationale  of  the  ter- 
minology, it  would  seem  proper  to  regard  collapse  as  a  more  severe 
degree  of  shock.  At  any  rate,  this  permits  of  uniformity  and 
avoids  confusion.  Shock  is,  of  course,  modified  in  degree,  though, 
as  already  stated,  no  absolute  standard  can  be  made  in  this 
connection.  As  a  general  rule,  shock  is  more  severe  in  so- 
called  nervous  persons  than  in  those  of  lymphatic  temperament, 
and,  of  course,  is  more  severe  in  persons  suffering  from  organic 
disease. 

Sudden  death  from  shock  is  explained  on  the  ground  that  a 
reflex  stimulation  of  the  nucleus  of  the  pneumogastric  nerve  in  the 
medulla  occurs,  which  arrests  cardiac  action.  This  is  called  death 
by  inhibition. 

Anything  which  extracts  heat  from  the  body  favors  the  oc- 
currence of  shock.  This  is  a  quite  rational  conception  if  it  be  true 
that  animal  heat  and  energy  are  mutually  convertible.  So  it  is 
also  true  that  the  conservation  of  animal  heat  during  operative 
manipulations  tends  to  prevent  shock,  and  the  application  of  arti- 
ficial heat  immediately  following  an  operation  would  seem  to  meet 
one  of  the  indications  presented  by  the  clinical  picture  of  post- 
operative shock.  As  a  rule,  the  bed  of  the  patient  is  prepared  with 
this  in  view  while  the  operation  is  in  progress,  and  as  a  routine 
the  bed  is  in  all  institutions  prepared  in  the  following  way. 

SHOCK   BED 

As  a  rule,  patients  are  best  managed  after  surgical  operations 
on  a  bed  which  has  no  mattress.  Not  infrequently  considerable 
manipulation  is  necessary  for  the  first  few  days  after  an  opera- 
tion, and  this  is  best  accomplished  on  a  hard  surface,  as  is  obtained 
by  the  wire  bed-spring.  As  already  stated,  the  bed  should  be  so 
located  as  to  permit  of  easy  access  to  the  patient  from  both  sides 
at  the  same  time.  The  wire  mesh  spring  is  covered  with  a  folded 
blanket  and  sheet.  This  is,  in  turn,  covered  with  a  rubber  sheet 
corresponding  to  the  middle  third  of  the  bed,  and  contact  with  the 
rubber  is  avoided  by  placing  upon  the  rubber  sheet  a  linen  sheet 


230  SHOCK   AND   SECONDARY   HEMORRHAGE 


Fig.  191. — Shock  Bed  with  Slip  Sheet.     Blocks  for  raising  foot  of  bed. 

folded  on  itself  to  the  necessary  size,  and  the  ends  twisted  about 
the  side  bar"  of  the  bed,  as  shown  in  Fig.  191.     The  two  blocks 


Fig.  192. — Shock  Bed.      With  foot-end  elevated  and  hot-water  bags  in  place. 
The  rubber  sheet  at  head  of  bed  prevents  soiling  with  vomit. 


SHOCK   BED 


231 


on  the  floor  are  used  to  raise  the  foot  of  the  bed,  as  shown  in  Fig. 
192.  Next  three  hot-water  bags  are  placed  on  the  bed  and  a  small 
rubber  sheet  is  laid  at  its  head,  with  the  view  of  preventing  soiling 
of  the  bed  linen  from  vomit,  which  is  usually  much  in  evidence 
immediately  after  narcosis.  The  center  draw  sheet,  too,  is  very 
liable  to  be  soiled  as  the  outcome  of  involuntary  evacuations  from 
the  bladder  and  rectum  at  this  time,  and  the  arrangement  here 
shown  permits  of  rapid  change  of  this  portion  of  the  bed  linen 
with  a  minimum  of  disturbance  to  the  patient.  Fig.  192  shows 
the  bed  arranged  as  mentioned  with  the  top  sheet  and  blanket 
turned  down  and  the  pillow  fastened  to  the  head  of  the  bed  ready 
to  be  placed  under  the  patient's  head  when  the  necessity  for  its 
absence  no  longer  obtains.      Fig.    193   shows   the  bed  completed 


Fig.  193. — Shock  Bed  Completely  Prepared  for  Receipt  of  Patient. 
Blocks  are  only  employed  when  indication  arises. 


as  it  should  be  before  the  patient  is  placed  upon  it.  This  prepara- 
tion is  exceedingly  elastic.  The  blocks  are,  of  course,  used  only 
if  shock  occurs,  thus  aiding  the  circulation  toward  the  vital  centers 
by  gravity.  The  hot-water  bags  are  in  the  last  moment  removed 
from  the  center  of  the  bed  and  placed  in  contact  with  the  patient 
as  the  indications  arise.     Care  should  be  taken  not  to  burn  the 


232  SHOCK   AND    SECONDARY    HEMORRHAGE 

patient  with  the  apparatus  used  to  furnish  artificial  heat.  It  is 
to  be  remembered  that  the  patient  is  not  conscious  at  this  time,  and 
is  in  no  position  to  standardize  sensory  impressions,  and  severe 
burns  have  occurred  as  the  outcome  of  lack  of  precaution  in  this 
regard. 

After  the  patient  has  been  put  to  bed  it  is  convenient  to  have 
close  at  hand  a  few  articles  which  are.  used  in  meeting  common 


Fig.   194. — Bedside  Table  with   Appliance  Used  Immediately  After 
the  Operation. 

contingencies.  A  pus  basin,  towel,  a  few  squares  of  gauze,  a  mouth 
gag,  and  a  pair  of  dressing  forceps  are  arranged  upon  a  table 
placed  at  the  bedside.  Fig.  194  shows  a  serviceable  arrangement 
in  this  regard.  The  pus  basin  may  be  apposed  closely  to  the 
patient's  cheek  and  effectually  catches  the  vomit.  In  some  in- 
stances the  lower  jaw  is  firmly  apposed  to  the  upper  teeth  and  the 


TREATMENT   OF   SHOCK  233 

vomit  regurgitates  and  may  be  aspirated  into  the  larynx  and 
trachea.  Indeed,  it  has  happened  that  patients  have  choked  to 
death  from  this  cause.  The  mouth  gag  meets  here  the  indication 
and  is  left  in  situ  until  sufficient  consciousness  recurs  to  obviate 
this  possibility.  As  soon  as  the  mouth  is  opened  the  gauze  wipes 
are  introduced  into  the  pharynx  with  the  dressing  forceps,  and 
the  vomit  removed.  The  towel  is  used  to  remove  excessive  quan- 
tities of  vomit  from  the  face.  To  facilitate  removal  of  the  vomit 
from  the  upper  passages  it  is  at  times  wise  to  raise  the  patient's 
shoulder  with  a  pillow  and  turn  the  head  to  the  opposite  side,  and 
to  raise  the  foot  of  the  bed  with  the  shock  blocks  (Fig.  192). 

These  manipulations  are  routine  and  are  employed  after  opera- 
tions irrespective  of  whether  shock  occurs  or  not.  The  application 
of  heat  has  already  been  shown  to  be  a  reasonable  precaution  with 
the  view  of  preventing  shock,  and  it  is,  of  course,  equally  reason- 
able to  assume  that  if  unnecessary  disturbances  from  vomiting  be 
avoided  this  desideratum  is  additionally  conserved. 

In  private  practice  or  in  an  emergency  this  rather  ideal  condi- 
tion of  affairs  may  not  be  practicable.  However,  the  hot-water 
bottles  may  be  replaced  by  hot  bricks,  bottles  filled  with  hot  wTater, 
a  hot  stove  lid,  or,  indeed,  any  apparatus  which  will  accomplish 
the  purpose.  The  table,  too,  need  not  be  of  white  enameled  steel, 
and  equally  good  service  will  be  rendered  by  an  ordinary  household 
table  or  a  flat  wooden  chair. 

TREATMENT   OF   SHOCK 

Beyond  the  measures  mentioned  of  conserving  animal  heat  and 
aiding  the  circulation  by  gravity,  the  treatment  of  shock  is  in  prin- 
ciple to  be  directed  toward  increasing  the  blood  pressure  by  creat- 
ing peripheral  resistance  either  by  drugs  acting  on  the  blood-ves- 
sels themselves  or  by  mechanical  pressure  (Crile).  The  infusion 
of  salt  solution  into  a  vein  (Fig.  207)  is  of  value,  but  its  effect  is 
transitory  except  in  cases  of  loss  of  blood.  The  writer  warns 
against  the  indiscriminate  use  of  infusion  of  salt  solution.  It  not 
infrequently  happens  that  the  house  staff  in  the  hospital  will  in- 
fuse in  this  way  a  patient  who  suffers  from  shock,  the  outcome  of 
the  severity  of  the  operative  trauma,  and  who  has  lost  very  little 
blood.     In  these  cases  saline  infusion  is  not  indicated.     The  in- 


234  SHOCK   AND   SECONDARY   HEMORRHAGE 

discriminate  use  of  strychnia  is  also  deprecated.  It  is  of  little 
value  as  a  stimulant  except,  perhaps,  in  collapse  from  mental  im- 
pression. Crile  has  demonstrated  this  experimentally.  Atropin, 
ether,  digitalis,  and  alcohol  should  be  given  with  caution,  and  only 
when  especially  indicated,  though  the  writer  is  free  to  admit  that 
these  special  indications  are  not  clearly  denned.  In  a  general  way, 
it  may  be  said  that  they  are  of  temporary  service  as  supplemen- 
tary to  the  methods  more  largely  discussed  here.  It  is  diffi- 
cult to  see  how  amyl  nitrate  or  nitroglycerin  can  be  of  use 
if  the  mechanism  of  shock  is  actually  understood.  Indeed, 
this  conception  is  borne  out  clinically.  Each  of  these  remedial 
agents  may  have  an  especial  field  of  usefulness  in  stimulating 
the  heart,  but  they  are  of  little  service  in  the  treatment  of  sur- 
gical shock. 

The  drug  which  has  given  palpable  results  and  owes  its  bene- 
ficial action  to  an  effect  it  produces  by  raising  the  blood  pressure, 
which  is  in  accord  with  our  understanding  of  the  mechanism  of 
the  affliction,  is  adrenalin  chlorid.  Adrenalin  chlorid  is  on  the 
market  in  a  solution  of  1  in  1,000.  Ten  to  thirty  minims  of  this 
may  be  given  hypodermatically  every  one  or  two  hours.  It  is,  how- 
ever, best  to  watch  the  effect  of  administration  and  vary  the  dosage 
and  intervals  of  administration  according  to  the  indications  as 
shown  by  the  pulse  and  respiration.  The  agent  may  be  added  to 
the  saline  venous  infusion  or  injected  with  salt  solution  under  the 
skin  or,  as  is  perhaps  most  frequently  done  in  cases  where  moderate 
shock  is  to  be  combated,  added  to  the  colic  injection.  The  indica- 
tions for  its  employment  in  the  latter  three  ways  will  be  taken  up 
under  a  separate  head. 

Senn  advises  the  administration  hypodermatically  of  thirty 
minims  of  sterile  camphorated  oil  every  fifteen  minutes.  As  the 
quantity  of  actively  circulating  blood  is  small,  the  amount  of 
oxygen  delivered  to  the  tissues  is  greatly  reduced.  The  inhala- 
tion of  oxygen  is,  therefore,  indicated.  However,  it  is  to  be  re- 
membered that  the  red-blood  corpuscles  will  take  up  only  a  certain 
amount  of  oxygen  and  their  carrying  capacity  does  not  increase  as 
the  quantity  of  blood  is  reduced.  This  suggests  that  the  remedy 
is  of  doubtful  value.  There  is  no  objection  to  its  use,  however, 
and,  indeed,  as  soon  as  the  blood  in  the  larger  veins  begins  to  cir- 
culate, respiration  may  be  assisted  in  this  way. 


TREATMENT  OF   SHOCK 


235 


HYPODERMIC   INJECTIONS 

A  word  in  this  connection 
regarding  hypodermic  injec- 
tions. The  usual  practice  is  to 
employ  for  the  purpose  a  long 
needle  (Fig.  195A),  which  is 
obliquely  introduced  through 
the  skin  as  it  is  "  pinched  "  up 
by  the  other  hand  (Fig.  196). 
The  objection  to  this  is  that 
a  considerable  number  of  hair 
follicles  and  glandular  elements 
of  the  skin  are  punctured,  fa- 
voring infection  and  subsequent 
abscess    formation.      Asjain,    a 

O  7 

wide  area  of  sensory  terminal 
fibers  are  subjected  to  trauma, 
causing  considerable  pain.  The 
writer  orders  the  injection 
made  with  a  very  short,  slen- 
der needle  (Fig.  195B),  which 
is  introduced  at'  right  angles 
to  the  surface  of  the  skin  (Fig.  197),  thus  avoiding  the  contin- 


A  B 

Fig.      195.  —  Hypodermic       Syringes. 

A,  Long    needle    usually    employed. 

B,  Short  needle. 


Fig.  196. — Usual  Method  of  Making  Hypodermic  Injections. 


236 


SHOCK  AND   SECONDARY   HEMORRHAGE 


gencies  mentioned.     Small  as  this  difference  may  seem,  it  is  an 
important  factor  when  repeated  injections  are  to  be  made  in  rapid 


Fig.  197. — A  Useful  Method  of  Making  a  Hypodermic  Injection. 

succession.  A  lesson  in  this  regard  may  be  gleaned  from  morphin 
habitues,  who  use  this  method  and  are  but  rarely  afflicted  with 
abscess. 

MECHANICAL    PRESSURE 

Mechanical  pressure  may  be  made  by  firmly  bandaging  the 
extremities  with  textile  fabric  or,  better  still,  with  elastic  rubber 


Fig.  198. — Crile's  Inflated  Rubber  Suit  for  Treatment  of  Shock.     (Bryant.) 


bandages.     Theoretically,  the  extremities  are  thus  excluded  from 
the  circulation  and  what  reduced  amount  of  blood  is  still  making 


TREATMENT  OF   SHOCK  237 

the  cycle  is  restricted  to  the  vital  organs.  This  measure  is  a  simple 
one  and  is  useful.  It  should  be  done  rapidly  so  as  not  to  un- 
necessarily expose  the  patient  to  the  influence  of  the  atmosphere. 
Crile  employs  a  complete  double  rubber  suit  (Fig.  198),  which 
completely  encases  the  patient,  and  the  space  between  the  two  lay- 
ers of  rubber  is  inflated  with  air.  This  is  perhaps  of  considerable 
service,  but  its  field  of  application  must  of  necessity  be  restricted 
to  a  certain  class  of  cases  and  under  certain  conditions. 

TRANSFUSION 

Transfusion  is  employed  to  overcome  shock.  Blood  intro- 
duced directly  from  one  person  to  another,  or  the  introduction  of 
defibrinated  blood,  has  been  largely  used  for  the  purpose.  How- 
ever, with  a  better  understanding  of  the  mechanism  of  shock,  the 
introduction  of  saline  fluid  into  the  body  has  largely  displaced  the 
former  method.  The  intent  of  the  introduction  of  fluid  into  the 
circulation  is  not  to  supply  nutritive  constituents  to  the  body  of 
the  afflicted,  but  to  furnish  a  mechanical  agent  upon  which  the 
circulating  organs  can  work  until  the  normal  relationship  is  estab- 
lished. The  object  is  accomplished  mechanically  by  a  salt  solu- 
tion as  well  as  by  blood  either  directly  from  another  or  defibri- 
nated outside  the  body  by  mechanical  manipulation,  and  is  not 
liable  to  undergo  chemical  changes  either  in  the  technic  of  in- 
troduction or  in  the  body  of  the  recipient  which  might  have  dele- 
terious effects. 

Heretofore  the  avenue  of  communication  between  the  donor 
and  recipient  has  consisted  of  mechanical  appliances,  and  if  it  be 
true  that  coagulation  of  the  blood  is  prevented  in  the  body  as  the 
outcome  of  contact  with  living  tissue,  the  passage  of  the  circu- 
lating fluid  through  the  cannula  must  of  necessity  permit  of  a  cer- 
tain chemical  change  in  the  blood  which  may  result  in  coagula- 
tion and,  perchance,  the  formation  of  emboli.  This  does  not 
apply  to  defibrinated  blood  with  regard  to  emboli,  but  it  is  difficult 
to  see  how  blood  which  has  been  subjected  to  the  necessary  ex- 
trinsic manipulations  which  obviate  clotting  can  be  of  use  in  any 
other  than  a  mechanical  way. 

The  objections  with  respect  to  the  direct  method  of  transfu- 
sion of  blood  have  been  largely  overcome  by  the  technic  employed 


238  SHOCK   AND   SECONDARY   HEMORRHAGE 

by  Crile,  from  whose  work,  "  Hemorrhage  and  Transfusion,"  the 
text  on  this  subject  is  quoted. 

Crile  states : 

The  transference  of  blood  from  one  individual  to  another  can  be 
safely  and  efficiently  done  only  by  the  union  of  the  supplying  vessel 
of  the  donor  to  the  receiving  vessel  of  the  recipient  in  such  a  manner 
that  the  continuity  of  the  intima  of  each  vessel  is  continuous  with  that 
of  the  other. 

The  problem' is  applied,  in  this  connection,  only  to  shock.  The 
question  of  hemolysis  is,  of  course,  not  taken  up  at  this  time  for 
this  reason. 

The  Direct  Transfusion  of  Blood. — By  following  Carrel's  technic 
it  is  possible  to  sew  together  the  ends  of  two  severed  blood-vessels  in 
such  a  way  that  when  the  blood  is  allowed  to  flow  through,  the  joint 
does  not  permit  leakage,  the  flow  is  uninterrupted,  and  clotting  does 
not  occur.  This  method  can  not  only  be  used  for  temporary  anasto- 
mosis, but  for  permanent  restoration  of  function.  As  developed  by 
the  author,  in  performing  transfusion  directly  from  one  individual 
to  another,  the  suture  method  was  employed  in  all  early  experimental 
and  clinical  work,  but  it  was  found  that  a  special  cannula  and  method 
of  using  it  took  less  time.  In  the  latter  work  the  cannula  has  come  to 
supersede  the  suture  for  making  all  temporary  anastomosis.  Both 
methods,  however,  will  be  described  in  detail. 

The  operator  will  find  the  technic  of  the  direct  anastomosis 
without  special  cannula  of  valuable  service  in  instances  such  as 
arise  in  connection  with  surgical  operations,  in  the  event  of  the 
necessary  special  instruments  not  being  available. 

The  Suture    Method  of    Blood-vessel  Anastomosis. — Instruments 

and  Material. — From  an  experience  with  over  100  blood-vessel  anas- 
tomoses made  in  the  laboratory,  and  more  than  60  clinical  cases,  the 
following  instruments  and  materials  have  been  found  to  be  most 
helpful.     (See,  also,  Fig.  199.) 

1.  Scalpel. 

2.  Blunt  director. 

3.  Small,  sharp-pointed,  straight  scissors  for  dividing    the    ves- 
sels, snipping  off  fragments  of  the  adventitia,  etc. 

4.  Ordinary  dissecting  forceps. 


i 


Fig 


199. — Instruments  Used  in  Performing  a  Transfusion  by  End-to-end 
Anastomosis  by  the  Cannula  Method.  1.  Scalpel.  2.  Blunt  dissector.  3, 
4.  Fine-pointed  forceps.  5,  6.  Crile  clamps  for  temporary  closure  of  blood- 
vessels. 7.  Fine-pointed  scissors.  8.  Hemostat  with  transfusion  cannula  locked 
in  place.  9,  10,  11.  Three  of  the  set  of  four  cannula.  12,  13,  14.  Mosquito  hemo- 
stats  for  placing  the  blood-vessels.     (Reduced  to  about  one-half  actual  size.) 

— Crile. 


239 


240  SHOCK  AND   SECONDARY   HEMORRHAGE 

5.  Minute  tissue  forceps  with  exact  approximation  at  the  points 
(those  used  by  watchmakers  have  been  found  to  be  useful). 

6.  Half   a    dozen   mosquito   hemostats    to    use   in    securing   the 
minute  branches  of  the  radial  artery  and  the  small  venous  branches. 

7.  A  pair  of  small  Crile  artery  forceps. 

8.  Xo.  16  English  needles  (Kirby's). 

9.  No.  1  Chinese  silk. 

10.  Sterilized  vaselin. 

11.  Ordinary  means  for  closing  a  wound,  and  dressings. 

After  experimenting  with  different  kinds  and  sizes  of  needles  it 
has  been  found  that  the  No.  16  round  needle  as  made  by  Kirby,  of 
London,  is  the  best.  A  No.  11  or  12  size  is  larger  and  easier  to  handle, 
but  has  the  disadvantage  of  causing  unnecessary  traumatism  of  the 
intima  and  tends  to  permit  oozing  through  the  needle  holes  when 
under  pressure.  Any  other  than  a  round  needle  of  about  this  size 
will  be  found  to  be  unsatisfactory. 

As  a  No.  16  needle  is  scarcely  larger  than  a  hair,  the  problem  of 
threading  it  is  a  difficult  one.  The  method  finally  adopted  to  secure 
suitable  sutures  was  to  take  a  piece  of  the  No.  1  Chinese  silk  or  "  000 
linen "  about  2  feet  in  length,  attach  a  hemostat  to  the  lower  end, 
carefully  separate  the  upper  end  into  its  component  strands  for  a  long 
enough  distance  to  permit  each  being  grasped  by  the  hands  of  the 
operator  and  a  hand  of  an  assistant,  and  then,  allowing  the  hemostat 
to  swing  free  and  pull  downward  as  the  twist  in  the  silk  made  it 
revolve,  hold  the  silk  until  it  was  untwisted  down  to  the  hemostat. 
This  gave  strands  capable  of  being  threaded  through  the  tiny  eye 
of  the  needle,  and  with  these  strands  the  sewing  was  -done. 

In  order  to  thread  a  needle,  such  a  strand  is  gently  pulled  at  the 
end  in  the  direction  of  its  long  axis  until  the  end  breaks.  This  leaves 
tiny  fibrils,  which  may  then  be  twisted  together  and  passed  through  the 
eye.  To  preserve  the  threaded  needle,  it  is  passed  in  and  out  at  2-inch 
intervals  through  a  long,  narrow  strip  of  gauze,  from  which  it  can 
easily  be  withdrawn  when  needed.  By  placing  several  threaded 
needles  in  one  strip  they  may  all  be  sterilized  together. 

Operation. — Having  the  ends  of  the  vessels  to  be  united  sufficiently 
near  each  other,  the  adventitia  of  the  artery  is  drawn  down  over  the 
end  by  means  of  the  fine-pointed  dissecting  forceps,  and  cut  squarely 
off  with  the  small  straight  scissors.  By  so  doing  the  adventitia  left 
on  the  vessel  retracts  and  leaves  a  free  field  for  inserting  the  sutures. 
The  vein  is  likewise  prepared.  Tben,  with  the  fine  silk  strand  thor- 
oughly  saturated  with   sterile   vaselin   or   oil,    the   needle   is   passed 


TREATMENT   OF   SHOCK 


241 


through  all  the  coats  of  the 
artery  from  without  inward 
near  the  cut  surface,  and 
passed  through  the  end  of 
the  vein  wall  in  the  oppo- 
site way.  The  two  vessels 
are  brought  intimately  in 
contact  by  tying  the  suture. 
The  ends  of  the  suture  are 
not  cut  close  to  the  knot, 
but  about  four  inches  from 
it.  This  gives  a  stay  suture 
to  hold  while  completing  the 
technic.  Two  more  similar 
stay  sutures  are  inserted 
with  the  circumference  of 
each  vessel  divided  into 
thirds  "between  them,  and 
if  the  stays  be  drawn  taut 
the  closely  approximated 
ends  of  the  artery  and  vein 
are  divided  into  three  equal 
parts,  so  as  to  form  an  equi- 
lateral triangle  (Carrel  and 
Guthrie). 

With  the  three  stay 
sutures  successfully  placed 
the  problem  becomes  a 
comparatively  easy  one. 
Tension  is  brought  to  bear 
on  any  two  of  the  stays — it 
is  immaterial  which  two  as 
long  as  the  third  one  lies 
underneath.  On  the  third 
Stay  an  inch  below  the  ves-  Fig.  200.— Diagrams  of  Stages  of  End-to- 
sels   is   attached   a   mosquito  END    Anastomosis    of    Two     Blood-ves- 

,  n  .   ,      .         ,,  ,  sels   by  the   Suture   Method.     (Carrel.) 

hemostat    which    IS    allowed  4,  Method  of  placing  the  three  stay-sutures, 

to     pull     theill     down,     and  They  are  equidistant  and  pass  through  the 

entire  thickness  of  the  vessel  walls.  B,  The 
stay-sutures  tied,  and  the  lower  angle  retracted  by  the  weight  of  a  hemostat.  C, 
placing  the  over-and-over  continuous  suture  between  two  of  the  stay-sutures.  The 
vessels  are  lifted  by  the  upper  sutures  in  the  hands  of  an  assistant,  so  as  to  make  an 
angle  between  the  vessels.  This  permits  easy  sewing  with  the  straight  needle.  D, 
The  anastomosis  completed.     (Crile.) 


242  SHOCK   AND   SECONDARY   HEMORRHAGE 

thus  prevent  the  needle  from  being  passed  through  the  lower 
part  of  the  vessel  walls  when  the  final  sutures  are  placed.  The  weight 
of  the  hemostat  is  too  small  to  damage  the  walls,  but  great  enough 
to  insure  complete  retraction  of  the  lower  angle.  With  the  three 
stays  thus  held  a  continuous ■•  over-and-over  suture  is  run  between 
the  upper  two,  placing  the  stitches  as  close  together  and  as  near  the 
ends  of  the  vessels  as  possible,  except  near  the  stays,  where  they  are 
placed  a  little  farther  away  in  order  to  include  the  stay  stitch  holes. 
With  one  third  completed,  the  tension  is  shifted  to  the  next  two  stays, 
and  the  hemostat  shifted  to  the  third  stay,  which  is  thus  brought 
underneath.  This  is  repeated  once  more,  and  by  that  time  the  anasto- 
mosis is  complete  and  ready  for  the  blood  to  flow  through.  It  should 
be  remembered  that  the  venous  clamp  should  always  be  removed  before 
the  arterial  clamp.  If  this  is  not  done  the  blood  rushes  against  the 
venous  clamp  under  arterial  pressure,  and  throws  too  great  strain  on 
the  anastomosis,  and  may  cause  leakage.  Even  if  one  or  two  drops 
of  blood  exude  when  the  clamps  are  properly  removed  no  further 
leakage  will  follow,  provided,  of  course,  that  the  sutures  have  been 
properly  placed.  The  operation  is  one  of  great  delicacy,  and  it  is 
essential  that  the  vessels  should  be  handled  with  extreme  gentleness, 
and  just  as  little  as  possible,  to  avoid  running  any  risk  of  causing 
clotting  (see  Fig.  200,  Crile). 

The  Cannula  Method  of  Blood-vessel  Anastomosis. — While  Dr.  S. 
J.  Mixter,  of  Boston,  was  the  first  to  call  the  author's  attention  to 
the  possibility  of  this  method,  Queirolo,  as  far  as  has  been  ascertained, 
was  the  first  to  use  an  anastomosis  tube  in  blood-vessel  surgery  as  it 
is  used  at  the  present  time.  Even  then  the  fundamental  principle 
did  not  originate  with  him,  but  with  another  investigator,  who  used 
it  in  making  intestinal  anastomoses.  Later  Payr  developed  the  idea 
much  more  extensively,  and  was  the  first  to  suggest  using  tubes  made 
of  magnesium  (the  metal)  which  would  be  absorbed  in  the  tissues 
and  permit  the  formation  of  permanent  anastomoses.  Neither  Payr 
nor  Queirolo  employed  the  short  handle  attached  to  the  tubes  which 
permits  easy  control  with  hemostatic  forceps  until  fixed  in  place — 
an  essential  improvement.  Payr  suggested  holding  them  by  means 
of  clamp  or  other  forceps  with  fine  points  which  could  be  inserted 
into  the  lumen  of  the  tube  with  the  entering  vessel,  but  it  is  obvious 
that  this  method  would  not  be  utilizable  with  very  small  vessels  owing 
to  lack  of  room  in  the  tube. 

Queirolo' s  description  of  his  method  is  as  follows:  "  The  isolated 
portion  of  the  portal  vein  is  drawn  through  a  short  glass  tube,  pulled 


TREATMENT  OF   SHOCK  243 

back  over  its  forward  edge,  and  bound  firmly  upon  it.  .  .  .  The 
glass  tube  thus  covered  by  the  vein  is  now  drawn  into  the  free  end  of 
the  vena  cava,  which  is  then  bound  on  the  glass  tube,  so,  however, 
tb at  the  first  loop  which  fastens  the  portal  vein  is  not  covered  by  the 
vena  cava.  The  artery  compression  forceps  are  loosened,  and  there- 
upon the  blood  streams  out  of  the  portal  vein  into  the  vena  cava  with- 
out touching  a  foreign  body,  and  only  coming  in  contact  with  the 
vessel  endothelium,  for  the  first  loop  touches  only  the  outer  wall  of 
the  portal  vein,  and  the  second  loop  only  the  outer  wall  of  the  vena 
cava.     .    .    ."     (Moleschott,  Untersuch.,  1895,  xx,  228-40). 

The  cannula  such  as  the  author  now  uses  was  developed  in  col- 
laboration with  Dr.  F.  W.  Ditchings.  To  be  able  to  use  vessels  of  dif- 
ferent sizes  different-sized  cannulae  have  been  made,  the  smallest  with 
an  inside  diameter  of  1.5  mm.,  the  next  half  a  millimeter  larger,  and  so 
on  up  to  3  mm.  It  has  been  found  by  experience  that  this  range  covers 
all  ordinary  cases  in  the  human  subject. 

The  instruments  used  when  the  cannula  is  employed  are  the  same 
as  those  used  in  carrying  out  the  suture  technic,  except  that  the  can- 
nula replaces  the  No.  16  needle  and  fine  suture.  The  vessels  to  be 
anastomosed  are  exposed  in  the  same  way  (the  details  will  be  described 
under  the  heading  of  the  general  management  of  a  transfusion  in 
the  following  pages),  and  after  selection  of  a  cannula  of  size  suitable 
to  the  size  of  the  vessels  the  end  of  the  vein  is  either  pushed  through 
the  handle  end  of  the  cannula  with  the  help  of  fine-pointed  forceps, 
or  pulled  through  by'  means  of  a  single  fine  suture  inserted  in  its  edge, 
the  needle  being  left  on  the  suture  and  passed  through  the  cannula 
ahead  of  the  vein.  The  handle  of  the  cannula  is  then  tightly  seized 
by  a  pair  of  hemostats  (the  fingers  are  too  clumsy),  three  mosquito 
hemostats,  or  small,  self-locking  forceps  such  as  oculists  use,  are 
snapped  at  equidistant  points  on  the  end  of  the  vein,  taking  care  not  to 
have  the  tips  extend  up  into  the  lumen  more  than  is  necessary  to  get  a 
firm  hold.  The  end  of  the  vein  is  then  cuffed  back  over  the  cannula  by 
gentle  simultaneous  traction  in  the  three  hemostats,  and  tied  firmly  in 
place  with  a  fine  linen  thread  in  the  groove  nearest  to  the  handle. 
The  cuffed  part  is  next  covered  with  sterile  vaselin,  being  careful  not 
to  get  any  into  the  open  end.  This  facilitates  slipping  the  artery 
over  the  cuff.  The  hemostats  are  removed  from  the  vessel  edge,  and 
the  artery  may  then  be  put  in  place. 

Owing  to  the  elasticity  of  the  arterial  wall  it  usually  shrinks  con- 
siderably when  the  pressure  from  within  is  removed,  as  it  is  at  the 
free  end.  To  obviate  this  it  may  be  necessary  to  dilate  the  end  very 
gently  by  inserting  the  closed  jaws  of  a  mosquito  hemostat  covered 
18 


244 


SHOCK  AND   SECONDARY   HEMORRHAGE 


with  vaselin,  and  opening  them  for  a  short  distance.  The  three  hemo- 
stats  are  then  applied  to  the  edges  just  as  with  the  vein,  and  the  artery 
is  gently  drawn  over  the  cuffed  vein  on  the  cannula  and  tied  in  place 
with  another  fine  linen  suture  applied  in  the  remaining  groove.  The 
mosquito  hemostats  are  removed,  and  finally  the  large  hemostat  which 
has  been  snapped  on  the  handle  of  the  cannula  during  all  this  time 
is  removed.  The  process  is  then  completed.  After  the  transfusion 
the  cannula  is  removed,  both  artery  and  vein  are  ligated,  and  the 
wounds  are  sutured  (see  Fig.  201.) 


Fig.  201. — Diagrams  of  Stages  of  End-to-end  Anastomosis  of  Two  Blood-vessels 
by  the  Cannula  Method  (as  modified  by  Cvile  and  Hitchings) .  A,  Pulling  the 
vein  through  the  cannula.  Very  fine  pointed  forceps  may  be  substituted  for  the 
single  suture.  B,  Cuffing  back  the  vein  over  the  cannula  with  three  mosquito 
hemostats.  C,  The  vein  cuffed  and  tied  in  place  in  the  groove  next  to  the  handle  of 
the  cannula.  The  artery  is  ready  to  be  drawn  over  the  vein.  D,  The  anastomosis 
completed,  and  the  cannula  hemostat  removed.  The  artery  is  tied  in  the  remain- 
ing groove.  The  short  handle  of  the  cannula  is  so  light  in  weight  that  it  does  not 
cause  torsion  of  the  vessels.     (Crile.) 


TREATMENT  OF   SHOCK  245 

In  making  a  cannula  anastomosis  experience  will  show  what  size 
cannula  is  suitable  for  the  given  vessels.  As  large  a  size  should  be 
used  as  possible  without  injuring  the  intima  of  the  artery  by  stretching 
it  too  much.  Usually  there  will  be  no  difficulty  in  obtaining  a  large 
vein,  but  the  artery  may  be  very  small.  If  too  small  a  cannula  is 
used,  the  amount  of  the  flow  will  be  diminished.  Moreover,  too  large 
a  vein  will  take  up  too  much  room  in  the  cannula,  and  the  amount  of 
flow  be  diminished. 

The  author  has  never  yet  found  a  radial  artery  so  small  that  the 
three  mosquito  hemostats  could  not  be  applied  to  its  edge  to  draw  it 
over  the  cuffed  vein.  If  preferred,  three  stay  sutures  may  be  used  in- 
stead of  the  hemostats,  but  they  will  tear  out  much  more  easily,  and  are 
not  so  easily  or  so  quickly  applied.  In  the  earlier  cases  the  artery  was 
cuffed  back  instead  of  the  vein,  and  the  vein  pulled  over.  It  was 
found  that  cuffing  back  the  artery  in  man  obstructed  the  lumen  of  the 
cannula  too  much,  and  was  often  a  very  difficult  procedure,  especially 
when  the  wall  was  at  all  calcined.  Besides,  with  a  calcified  wall 
there  was  too  much  danger  of  tearing  the  intima  in  the  process  of 
cuffing.  Apparently  there  is  no  danger  of  clotting  when  done  either 
way,  but  to  cuff  back  the  vein  is  the  better  method. 

In  using  the  cannula  two  facts  should  be  particularly  remembered. 
The  first  is  that  the  long  axis  of  the  tube  should  coincide  with  the 
long  axis  of  the  lumen  of  the  vein  and  artery.  A  little  experiment- 
ing will  show  how  easily  the  cannula  may  be  made  to  slant  so  that 
the  opening  in  it  will  come  almost  in  contact  with  the  artery  wall, 
and  shut  off  the  flow  in  great  part  or  completely.  Actual  experience 
has  shown  the  necessity  of  placing  the  cannula  accurately. 

The  second  and  less  obvious  fact  is  that  unless  the  right  amount 
of  tension  is  maintained  on  the  vessel  which  passes  through  the  can- 
nula when  the  blood  is  flowing  across,  particularly  with  a  small  can- 
nula, the  flow  will  be  diminished  or  shut  off  altogether  by  the  elas- 
ticity of  the  vessel  wall  on  tension  in  the  cannula  pulling  the  outside 
part  of  the  vessel  in  and  blocking  the  way.  This  is  more  likely  to 
happen  with  the  artery  drawn  through  the  tube  than  with  the  vein, 
owing  to  the  greater  elasticity  of  the  arterial  wall.  It  may  be  very 
prettily  demonstrated  by  drawing  an  artery  through  a  small  cannula, 
cuffing  it  back,  and  tying  it  in  place.  On  removing  the  clamp  con- 
trolling the  flow  no  blood  will  appear  at  the  open  end  of  the  artery, 
or  at  most  the  flow  will  be  very  small  and  weak.  On  putting  gentle 
tension  on  the  tube  by  drawing  it  out  a  little  in  the  direction  of  the 
long  axis  of  the  artery,  the  wall  puckered  up  in  the  cannula  will  be 
pulled  out  and  the  blood  will  spurt  sometimes  as  far  as  three  feet. 


246  SHOCK  AND   SECONDARY   HEMORRHAGE 

The  exposed  vessels  should  he  kept  moist  with  warm  normal  saline 
solution.  Not  only  is  drying  harmful,  but  the  flow  is  increased 
through  gradual  relaxation  of  the  arterial  wall. 

Experience  has  shown  that  if  anything  goes  wrong  in  carrying  out 
this  technic  it  is  best  to  start  again  from  the  beginning,  and  not  to 
try  to  get  around  any  of  the  details  by  substitution.  For  example, 
if  one  of  the  three  mosquito  hemostats  slips  from  the  end  of  the  vessel 
which  is  being  either  cuffed  or  drawn  over,  the  attempt  should  not  be 
continued  until  the  vessel  has  been  removed  and  the  hemostat  is  accu- 
rately replaced.  Xot  only  will  valuable  time  be  lost  in  trying  to  sub- 
stitute ordinary  forceps  for  the  slipped  hemostat,  but  the  danger  of 
tearing  the  intima  is  much  greater.  For  the  average  surgeon,  at 
least,  it  is  essential  to  have  the  instruments  lock  firmly  in  place  on 
the  vessel  edge.  Then,  if  one  be  dropped  from  the  hand  it  does  not 
have  to  be  reapplied  when  picked  up.  For  this  reason  ordinary  for- 
ceps are  entirely  unsuitable,  and  anyone  endeavoring  to  use  them 
takes  on  himself  the  responsibility  of  the  possible  occurrence  of  clot- 
ting, or  of  inability  to  finish  the  technic.  Every  detail  has  been 
worked  out  over  and  over  again,  and  while  there  is  doubtless  plenty 
of  room  for  improvement,  it  is  felt  that  every  detail  should  be  exactly 
followed,  at  least  until  the  operator  has  convinced  himself  that  any 
modification  is  suitable.  It  will  be  found  that  the  use  of  the  anas- 
tomosis cannula  is  much  less  difficult  than  the  use  of  the  suture 
method,  the  results  are  more  certain,  and  the  time  of  operation  much 
shorter. 

The  General  Management  of  a  Transfusion. — Having  carefully 
considered  the  technic  of  end-to-end  anastomosis  of  blood-vessels  by 
the  suture  and  cannula  methods,  we  come  to  its  practical  application 
in  performing  direct  transfusion  from  one  human  being  to  another. 
First  of  all  a  suitable  donor  must  be  obtained.  It  is  assumed  here 
that  all  the  requirements  have  been  successfully  met.  and  that  both 
donor  and  recipient  are  in  readiness. 

It  is  of  great  advantage  to  have  a  thoroughly  trained  corps  of  as- 
sistants. A  full  staff  would  include  first  and  second  assistants,  a 
nurse  to  handle  the  sponges,  sutures,  etc.,  a  nurse  to  devote  herself 
entirely  to  the  comfort  of  the  patients,  an  instrument  nurse  to  pass 
between  the  operating  and  sterilizing  rooms,  and  an  orderly.  If 
special  investigations  are  to  be  made — for  example,  of  changes  in  the 
blood — others  must  be  added  as  needed.  All  should  be  able  to  work 
noiselessly  and  rapidly. 

The  operating  room  should  have  all  the  ordinary  equipment.  Two 
operating  tables  are  necessary,  one  for  each  patient.     They  should  be 


TREATMENT   OF   SHOCK 


247 


of  the  type  which  allows  the  patient  to  be  easily  changed  from  a  hori- 
zontal to  a  head-up  or  head-down  position,  so  as  to  permit  combating 
either  cerebral  anemia  or  acute  cardiac  dilatation.  They  should  be 
well  provided  with  pillows  with  which  to  make  the  patient  as  comforta- 
ble as  possible.  Two  small  square  tables  of  the  same  height  as 
the  operating  tables  are  also  needed — one  for  the  instruments, 
and  the  other  to  support  the  arms  of  the  patients.  Two  low 
stools,  one  for  the  surgeon  and  one  for  the  first  assistant,  com- 
plete the  list. 

From  twenty  to  thirty  minutes  before  being  brought  to  the  operat- 


□ 
O 

1. 

Q, 

a. 

Fig.  202. — Diagram  op  Arrangement  of  Operating  Room  for  a  Transfusion. 
1,  2.  Operating  tables  for  recipient  and  donor,  respectively.  3.  Table  for  arms 
of  recipient  and  donor.  4,  5.  Stools  for  surgeon  and  first  assistant,  respectively. 
6.  Instrument  table.     7.  Table  for  dressings,  sutures,  etc.     (Crile.) 


ing  room  the  donor  and  recipient  each  receive  y±  of  a  grain  of  mor- 
phin  hypodermically,  unless  there  is  some  special  reason  for  its  being 
contraindicated.  The  patients  are  assured  that  they  will  experience 
no  pain  beyond  the  first  needle  prick. 

When  each  is  in  place  on  his  respective  operating  table  the  tables 
are  arranged  so  that  the  left  arm  of  each  will  rest  comfortably  on  the 
small  square  table  placed  for  the  purpose  between  the  operating  tables 
(see  diagram,  Fig.  202).  In  order  that  no  glimpses  of  the  surround- 
ing room  may  be  had  the  face  of  each  is  covered  with  a  damp  towel 
"to  avoid  too  much  bright  light  and  headache."     The  operator  and 


248  SHOCK  AND   SECONDARY   HEMORRHAGE 

first  assistant  sit  between  the  operating  tables  on  opposite  sides  of 
the  small  square  table.  The  other  small  square  table  with  the  instru- 
ments on  it  is  placed  conveniently  for  the  second  assistant.  The 
patients  are  again  told  that  there  will  be  no  pain  beyond  the  first 
prick.  The  nurse  detailed  to  care  directly  for  the  patients  relieves 
the  monotony  of  waiting  by  changing  the  wet  towels,  bathing  the  fore- 
head, giving  water  to  drink  if  desired,  and  in  short  doing  anything 
permissible  to  afford  comfort. 

The  next  step  is  the  dissection  of  the  blood-vessels  to  be  used. 
Experience  has  shown  that  it  is  best  to  use  a  radial  artery  of  the 
donor  and  any  superficial  arm  vein  of  the  recipient  near  the  elbow. 
Usually  the  median  basilic  vein  is  the  best  one  on  account  of  its  size 
and  easily  accessible  position. 

Local  anesthesia  is  obtained  by  injecting  cocain  in  1/10  of  1  per 
per  cent,  solution  with  a  few  drops  of  1-1,000  adrenalin  chlorid  solu- 
tion. Several  hypodermic  syringes  should  be  ready  so  that  there 
need  be  no  delay  on  account  of  having  to  stop  to  refill  a  single  one. 
The  injections  are  first  made  into  the  skin,  and  then  more  deeply 
around  the  vessels.  After  this,  firm  pressure  is  applied  by  the  hand 
over  a  gauze  sponge  to  insure  thorough  spreading  of  the  cocain 
through  the  tissues.  When  carefully  performed  there  is  absolutely 
no.  pain  in  any  part  of  the  technic  until  the  sutures  are  placed  in  the 
skin  at  the  end  of  the  transfusion.  By  then  the  effect  of  the  cocain 
bas  usually  worn  away. 

In  making  the  dissection  it  is  necessary  to  have  good  light. 
Mosquito  hemostats  are  used  to  catch  every  vessel  that  sheds  even  a 
drop  of  blood.  The  field  should  be  kept  absolutely  clear.  The  donor's 
radial  artery  is  isolated  for  a  distance  of  about  3  cm.  at  the  point  of 
election  in  the  wrist.  Here  there  are  a  number  of  small  side  branches 
which  must  be  carefully  isolated  and  tied  with  No.  1  Chinese  twist 
silk  (which  has  not  been  split  up  into  strands)  before  being  cut.  The 
artery  is  then  tied  at  its  distal  end,  and  a  Crile  clamp  is  gently 
screwed  in  place  over  the  proximal  part  as  near  to  the  place  where  it 
comes  out  of  the  undissected  tissues  as  convenient.  The  clamp  should 
be  screwed  up  with  great  care.  Just  enough  pressure  should  be  used 
to  control  the  flow  of  blood  without  causing  injury  to  the  vessel  wall. 
The  artery  is  severed  with  sharp  scissors  a  short  distance  from  where 
it  is  tied  off,  the  end  cut  squarely  across,  the  adventitia  pulled  down 
and  cut  off  as  directed  under  the  technic  of  making  an  anastomosis 
by  either  the  suture  or  the  cannula  method,  and  is  then  ready  for 
the  completion  of  the  anastomosis.  The  result  should  be  that  the 
operator  has  about  2y2  cm.  of  exposed  radial  artery  free  from  branches, 


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250  SHOCK  AND   SECONDARY  HEMORRHAGE 

the  cut  end  open,  and  the  blood  prevented  from  coming  out  of  it  by 
the  clamp. 

The  next  step  is  the  dissection  of  the  vein.  It  is  exposed  for  the 
same  distance  as  the  artery,  the  branches  are  tied  off  in  the  same  way, 
and  the  ligature  is  also  applied  at  the  distal  end.  The  second  Crile 
clamp  is  applied  just  as  before,  the  vein  cut  near  the  ligature,  and  it 
in  turn  is  ready  for  the  completion  of  the  anastomosis. 

The  anastomosis  is  made  either  by  the  suture  or  the  cannula 
method  as  described  in  the  previous  pages.  The  details  will  not  be 
repeated  here.  It  may  be  said  that  in  practically  all  cases  the  can- 
nula method  should  be  used  rather  than  the  suture  method.  In  order 
to  meet  possible  emergencies,  however,  the  operator  should  be  prepared 
to  carry  out  either.  It  seems  to  the  author  that  neither  should  be  at- 
tempted on  the  human  subject  until  experience  has  been  gained  in  the 
laboratory. 

With  the  anastomosis  completed,  the  questions  which  then  arise 
are  how  much  blood  should  be  allowed  to  pass  over,  how  fast  to  allow 
it  to  pass  over,  and  what  will  happen  if  the  limits  of  safety  are  passed. 
So  many  points  must  be  considered  in  answering  these  and  other  ques- 
tions that  the  problems  presented  by  the  donors  and  recipients  will 
be  discussed  separately. 

The  Donor. — It  has  been  proved  many  thousands  of  times,  either 
directly  through  hemorrhage  or  indirectly  through  transfusion,  that 
loss  of  blood  to  even  a  considerable  amount  may  occur  and  the  indi- 
vidual survive.     In  normal  individuals  lost  blood  is  quickly  replaced. 

Another  fundamental  fact  is  that  while  the  blood  of  the  donor  may 
convey  life  to  the  sick  person,  it  may  also  convey  death  in  the  form 
of  disease.  As  far  as  can  be  determined  the  giver  of  the  blood  should 
be  free  from  any  constitutional  or  other  disease  which  might  be 
engrafted  on  the  patient. 

A  donor  may  usually  be  readily  obtained.  Both  men  and  women 
are  suitable.  In  cases  in  which  no  immediate  hurry  exists  the  best 
subject  is  selected  from  among  the  relatives  and  friends  who  are  will- 
ing to  serve.  The  gravity  of  the  patient's  condition  and  the  reason 
for  wishing  to  transfuse  are  carefully  explained  in  detail,  and  the 
painlessness  of  the  operation  to  both  donor  and  recipient  is  assured. 
Almost  always  the  offer  to  serve  is  made  voluntarily.  In  fact  an 
entire  family  and  numerous  friends  have  frequently  been  eager  to 
do  so. 

The  only  difficulty  which  has  been  encountered  thus  far  has  been 
among  ignorant  people,  who  may  have  a  certain  amount  of  distrust 
of  both  surgeons  and  hospitals.     Even  among  such  people,  however, 


TREATMENT  OF   SHOCK  251 

but  one  refusal  has  been  experienced.  In  this  particular  case  the 
parents  of  the  patient,  a  nine-)rear-old  child  whose  legs  had  been 
crushed,  refused  to  assist,  their  argument  being  that  the  child  was 
so  much  mutilated  by  the  injury  that  it  was  not  worth  saving ! 

In  two  instances  among  the  authors  cases  donors  were  hired. 
In  these  instances  the  commercial  attitude  was  apparent,  and  they  were 
not  as  tractable  as  those  who  responded  to  the  appeal  of  sentiment. 

After  the  donor  has  been  selected  he  is  subjected  to  a  thorough 
cross-questioning  as  to  his  family  and  personal  history,  and  a  thorough 
physical  examination.  This  is  for  his  own  benefit  as  well  as  for  the 
benefit  of  the  patient,  as  in  some  cases  it  has  been  proven  inadvisable 
to  bleed  the  would-be  donor. 

In  all  the  authors  cases  the  regeneration  of  the  blood  lost  by  the 
donors  was  uninterrupted  and  rapid.  This  statement  is  based  on  their 
general  appearance  subsequent  to  losing  the  blood,  their  freedom  of 
symptoms  suggestive  of  the  experience  through  which  they  had 
passed,  and,  more  particularly,  on  the  blood  examinations  made  in  as 
many  cases  as  was  possible  under  the  particular  conditions  of  each 
individual  case.  In  no  case  was  there  anything  but  a  temporary  dis- 
turbance of  the  general  functions.  Apparently  the  return  to  normal 
varied  directly  according  to  the  amount  of  blood  lost — the  more  that 
was  lost  the  longer  the  lapse  of  time  before  the  return  to  the  original 
amount. 

The  amount  of  blood  which  is  allowed  to  pass  from  donor  to 
recipient  varies  according  to  a  considerable  number  of  factors.  These 
may  be  tabulated  as  follows: 

1.  The  duration  of  the  flow. 

2.  The  size  of  the  radial  artery  and  the  elasticity  of  its  wall. 

3.  The  blood  pressure  of  the  donor. 

a.  The  normal  pressure. 

b.  The  pressure  as  affected  by  psychic  influences. 

4.  The  method  of  making  the  anastomosis. 

a.  The  suture  method. 

(1)    The  accuracy  with  which  the  suture  is  made  (leak- 
age, reduction  of  size  of  lumen). 

b.  The  cannula  method. 

(1)  The  accuracy  with  which  the  connection  is  made 
(turning  the  tube  sideways). 

(2)  Adaptation  of  cannula  to  size  of  vessel. 

(3)  The  tension  on  whichever  vessel  passes  through  the 
cannula  (see  previous  explanation). 


252  SHOCK  AND   SECONDARY   HEMORRHAGE 

(4)  Whether  the  vein  or  the  artery  passes  through  the 
cannula  (on  account  of  the  varied  thickness  of 
wall). 

(5)  The  resistance  offered  by  the  vascular  system  of 
the  recipient. 

It  is  necessary  to  discuss  but  two  of  these  factors  here,  as  the  others 
are  discussed  in  appropriate  places  elsewhere.  From  the  donor's 
standpoint  the  duration  of  the  flow  is  an  important  consideration. 
The  best  way  of  determining  when  to  stop  the  flow  is  by  watching 
his  symptoms.  At  first  he  will  show  loss  of  color  in  his  mucous  mem- 
branes, pallor  of  the  skin,  slight  uneasiness,  slight  quickening  of  the 
pulse  and  respiration,  lowering  of  the  blood  tension,  and  beginning 
shrinkage  in  the  skin  of  the  face.  Progressive  hemoglobin  determi- 
nations often  furnish  a  good  index  of  the  general  condition,  and  may 
be  easily  made.  All  of  the  symptoms  are  progressive,  and  as  soon 
as  they  are  well  marked  the  flow  should  be  stopped.  Often  the  con- 
dition of  the  recipient  will  necessitate  this  long  before  the  donor 
shows  any  symptoms  at  all.  Definite  rules  cannot  be  laid  down. 
Everything  will  depend  on  the  judgment  and  experience  of  the  sur- 
geon. Temporary  cerebral  anemia  can  be  readily  controlled  by  chang- 
ing the  donor  from  the  horizontal  to  the  head-down  position. 

'  The  approximate  determination  of  the  amount  of  blood  which  is 
lost  can  be  made  by  carefully  weighing  the  donor  to  fractions  of  an 
ounce  before  and  after  the  transfusion.  The  conditions  of  the  weigh- 
ing must  be  the  same  at  each  time.  It  is  futile  to  attempt  to  calculate 
the  amount  of  transfused  blood  from  direct  observation  of  the  loss 
of  a  few  cubic  centimeters  in  a  given  time  from  the  radial  artery. 
A  few  experiments  have  been  done  in  the  laboratory  which  showed 
how  much  the  rate  of  flow  varied  as  the  flow  progressed,  and  how  use- 
less the  attempt  was  to  obtain  accurate  calculated  results. 

That  the  blood-pressure  may  be  markedly  varied  by  reason  of 
psychic  influences  has  been  repeatedly  demonstrated  by  many  differ- 
ent observers.  It  is  largely  for  this  reason  that  the  elimination  of 
disturbing  influences  at  the  time  of  the  operation  is  so  important. 
This  is  accomplished  not  only  by  the  previous  dose  of  morphin,  but 
by  the  noiselessness  of  a  perfectly  equipped  and  smoothly  run  operat- 
ing room. 

A  final  point  must  be  considered  in  regard  to  the  protection  of  the 
donor  against  injury,  and  that  is  the  possibility  of  his  becoming  in- 
fected from  contact  of  his  artery  with  the  vein  of  the  recipient  in 
cases  in  which  transfusion  is  performed  for  an  infectious  disease,  and, 


TREATMENT   OF   SHOCK  253 

more  particularly,  one  which  is  acutely  infectious.  In  the  author's  cases 
of  hemorrhages  in  typhoid  fever  the  donors  were  purposely  chosen  be- 
cause they  had  had  typhoid.  The  possession  of  immunity  would  in  itself 
protect  the  donor  in  such  a  case  as  well  as  the  unusual  care  taken  to 
avoid  exposure.  The  author  believes  that  there  is  little  or  no  risk  in 
a  chronic  infection  like  tuberculosis  or  from  an  old  septicemia  or 
mixed  infection.  This  is  largely  due  to  the  fact  that  there  is  no  chance 
for  the  blood  being  forced  back  from  the  recipient  into  the  donor 
against  the  donor's  arterial  pressure.  At  the  end  of  the  transfusion 
there  is  a  good  margin  of  safety  as  regards  any  of  the  possible  infec- 
tion in  the  vein  of  the  recipient  being  retained  by  the  donor,  as  the 
donor's  artery  may  be  severed  at  least  2  cm.  from  the  point  of  anasto- 
mosis. Moreover,  the  exposed  tissues  may  be  freely  irrigated  with 
corrosive  sublimate  in  1-2,000  solution.  The  exact  amount  of  risk 
from  this  source  must  be  very  small,  and  with  care  as  suggested  it 
hardly  seems  likely  that  the  danger  of  infection  need  ordinarily  be 
feared.  At  all  events,  cases  of  acute  infection  rarely  require  trans- 
fusion. 

The  Recipient. — The  question  as  to  what  pathologic  conditions 
may  be  suitably  treated  by  transfusion  of  blood  from  one  human  being 
to  another  has  not  been  definitely  settled.  The  most  that  can  be  said 
at  present  is  that  it  is  clearly  indicated  in  certain  conditions  and  as 
clearly  contraindicated  in  certain  others.  With  our  present  knowl- 
edge the  author  feels  that  it  should  be  used  only  when  all  other 
resources  at  command  have  failed. 

Cases  are  on  record  in  which  transfusion  was  said  to  have  been 
followed  by  recovery  when  in  reality  the  patient  died  of  the  disease,  and 
on  the  other  hand  deaths  were  said  to  have  occurred  from  the  disease 
when  they  should  undoubtedly  have  been  ascribed  to  accidents  of 
transfusion. 

As  far  as  the  recipient,  is  concerned,  transfusion  is  a  problem  in 
mechanics  as  well  as  in  therapeutics.  There  are  certain  dangers 
which  must  be  avoided  under  both  of  these  headings,  and  in  the  recog- 
nition of  their  existence  and  their  successful  avoidance  lies  the  respon- 
sibility of  the  surgeon.  There  are  few  if  any  operations  in  which 
more  factors  must  be  considered,  and  in  which  more  care  must  be 
exercised. 

From  the  mechanical  standpoint  the  chief  danger  to  be  feared  is 
acute  cardiac  dilatation  and  subsequent  cardiac  failure  caused  by 
transfusion  in  excessive  amount  or  at  excessive  rate  of  flow.  This 
danger  is  particularly  great  when  the  vitality  of  the  patient  is  much 
lowered  in  the  course  of  a  severe  illness,  or  when  any  previous  func- 


254  SHOCK  AND   SECONDARY   HEMORRHAGE 

tional  or  organic  cardiac  complication  is  present.  Fortunately,  as 
has  been  frequently  shown  in  the  author's  series  of  cases,  a  certain 
amount  of  dilatation  may  occur  and  pass  rapidly  away  without  caus- 
ing either  immediate  or  subsequent  harm. 

The  best  treatment  of  acute  cardiac  dilatation  is  prevention.  If 
the  blood-pressure  of  the  donor  is  high  and  his  radial  artery  large, 
too  rapid  a  flow  may  be  prevented  by  partially  narrowing  the  lumen  of 
the  artery  with  gentle  pressure  of  the  fingers.  The  effect  can  be 
gauged  by  the  changes  in  the  strength  of  the  pulsation  beyond  the 
cannula  in  the  vein.  It  may  be  necessary  to  shut  off  the  flow  alto- 
gether for  short  intervals,  giving  the  heart  a  chance  gradually  to 
assume  its  added  burden  by  allowing  only  small  amounts  of  blood 
to  pass  across  at  a  time. 

As  another  means  of  prevention  of  acute  cardiac  dilatation,  it  may 
be  necessary  to  bleed  the  recipient  freely  before  transfusion.  In  cases 
of  shock  or  of  acute  hemorrhage  a  preliminary  bleeding  would  do 
harm.  In  many  cases  of  subacute  hemorrhage  it  is  unnecessary. 
In  all  other  cases  either  a  preliminary  bleeding  must  be  performed  or 
the  amount  of  blood  transfused  must  be  much  smaller  than  would 
otherwise  be  possible,  and  the  care  taken  correspondingly  great.  It 
should  be  remembered  that  reduction  in  the  corpuscular  elements  in 
the  blood  of  the  recipient  does  not  necessarily  mean  reduction  in  the 
fluid  content  (as,  for  example,  in  pernicious  anemia),  and  also  that 
where  saline  infusion  would  rapidly  pass  out  of  the  vascular  system 
blood  will  be  retained.  In  cases  where  great  weakness  of  the  patient 
is  associated  with  marked  reduction  of  the  red  corpuscles  it  may  be 
unsafe  to  bleed  unless  the  bleeding  be  done  at  the  same  time  that  the 
transfusion  is  progressing. 

Another  phase  of  the  mechanics  of  transfusion  is  the  possible 
transudation  of  the  blood  into  the  tissues  or  body  cavities  with  or 
without  rupture  of  small  vessels  in  the  parenchymatous  organs.  This 
possibility  may  be  disregarded  in  human  beings,  as  symptoms  of  car- 
diac distress  will  occur  long  before  there  is  any  danger  of  transudation. 

The  principal  symptoms  of  acute  cardiac  dilatation  are  dyspnea,  dis- 
tress or  pain  in  the  precordial  region,  cough,  and  cyanosis.  The  pulse 
increases  in  rate  and  may  be  very  irregular  in  action,  tension,  and 
volume.  The  right  heart  is  chiefly  affected.  Percussion  over  the  right 
border  may  give  dullness  extending  out  as  far  as  an  inch  from  the 
border  of  the  sternum.  Unless  the  strain  on  the  heart  is  immediately 
relieved  the  increase  in  severity  of  the  symptoms  is  rapid,  and,  if 
allowed  to  go  too  far,  death  will  result.  The  rapidity  with  which  a 
heart  will  dilate  and  return  to  its  previous  size  is  sometimes  remark- 


TREATMENT   OF   SHOCK  255 

able.  This  fact  should  never  be  counted  on,  however,  as  a  means  of 
getting  out  of  difficulties  brought  on  by  over-transfusion. 

When  acute  dilatation  has  once  occurred  it  must  be  promptly  rec- 
ognized. The  transfusion  must  be  stopped,  the  operating  table  tilted 
so  as  to  raise  the  patient  to  the  head-up  position,  and  rhythmic  pressure 
made  on  the  chest  over  the  heart. 

If  recovery  is  not  complete  in  a  short  time  the  transfusion  should 
be  given  up,  and  the  patient  put  to  bed  in  a  head-up  posture,  given 
carefully  graded  doses  of  nitroglycerin  to  insure  peripheral  dilatation 
of  the  vessels,  and  digitalin  hypodermically  in  very  small  closes  to 
stimulate  the  heart  muscle  directly.  Small  does  of  morphin  may  also 
be  given  if  needed,  but  it  must  be  remembered  that  the  recipient  has 
had  14  of  a  grain  before  the  transfusion.  Absolute  rest  and  quiet  and 
a  reduction  of  the  amount  of  fluids  ingested  are  also  requisite.  Such 
a  patient  needs  careful  watching  with  treatment  of  the  symptoms  as 
they  arise. 

The  treatment  of  shock  and  of  acute  hemorrhage  by  transfusion 
is  primarily  mechanical  in  its  nature,  and  need  not  be  discussed  fur- 
ther here  under  the  general  considerations.  The  treatment  of  all  other 
conditions,  however,  is  a  question  of  therapeutics  when  reduced  to  its 
final  analysis.  The  surgeon  takes  the  place  of  the  internist  when  he 
gives  a  "close  "  of  blood. 

In  the  therapeutics  of  transfusion  there  is  a  possible  danger  to 
be  considered.  In  certain  diseases,  when  similar  bloods  are  inter- 
mingled (i.  e.,  blood  from  animals  of  the  same  species), what  is  ordi- 
narily designated  as  "  hemolysis "  occasionally  occurs.  Agglutina- 
tion of  the  red  corpuscles  and  precipitation  may  also  occur,  hut,  from 
a  practical  standpoint  at  least,  the  author  has  had  no  reason  to  believe 
that  these  two  last  changes  may  be  regarded  as  possible  sources  of 
danger. 

The  mistake  must  not  be  made  of  considering  "hemolysis"  as 
destruction  of  the  red  corpuscles  alone.  It  would  be  more  appropriate 
to  say  that  "hemolysis  "  is  a  toxic  condition  which  gains  its  name  from 
the  fact  that  the  red  corpuscles  are  destroyed  to  a  greater  or  less  ex- 
tent, but  that  one  of  the  effects  is  not  the  cause.  Hemolytic  destruc- 
tion of  red  corpuscles  is  one  matter,  but  toxemia  is  another.  The 
serum  of  the  pathologic  blood  may  act  as  a  poison  and  incidentally 
destroy  certain  of  the  red  corpuscles.  When  the  amount  is  large, 
appreciable  changes  probably  take  place  in  the  parenchymatous  organs 
such  as  occur  when  dissimilar  blood  is  transfused.  It  is  a  question  as 
to  whether  the  interaction  of  similar  serum  on  the  red  corpuscles  and 
on  the  other  organs  does  not  cause  the  formation  of  new  toxic  sub- 


256  SHOCK  AND   SECONDARY   HEMORRHAGE 

stances  which  was  previously  present  in  neither — i.  e.,  that  it  is  more 
than  the  poisonous  action  of  the  serum  alone  which  must  be  held 
responsible.  Moreover,  may  not  a  possible  role  of  the  leucocytes  be 
overlooked  when  the  red  cells  alone  are  considered  ? 

The  pathologic  changes  which  follow  injection  of  dissimilar  blood 
have  been  studied  by  Hasse  and  his  followers  and  others.  The  extent 
of  the  lesions  varies  considerably  for  a  given  animal,  according  to  the 
species  from  which  the  blood  is  taken,  serum  from  one  species  being 
more  toxic  than  that  from  another;  but  the  extent  varies  still  more 
with  the  amount  of  blood  transfused.  It  seems  reasonable  that  there 
should  be  a  direct  ratio  between  the  dosage  and  the  effect  produced, 
just  as  there  is  in  giving  a  drug.  While  a  small  amount  of  a  given 
enzyme  will  hydrolyze  a  disproportionately  large  amount  of  organic 
substance  without  losing  its  powers,  there  is  no  evidence  of  any  similar 
action  occurring  between  toxic  serum  and  the  blood  or  other  cells  of 
the  recipient. 

From  the  above  it  may  be  deduced  that  the  question  of  dosage  may 
be  very  important,  especially  when  there  is  hemolysis  of  the  recipient's 
red  corpuscles  by  the  donor's  serum.  Therefore,  in  all  but  emergency 
cases  preliminary  hemolysis  tests  should  be  made  in  order  to  handle 
a  given  transfusion  more  intelligently  and  protect  the  recipient  more 
fully.  The  technic  to  be  followed  in  making  these  tests  is  described 
in  a  following  chapter. 

The  author  has  had  but  one  case  in  which  serious  hemolysis 
occurred.  The  patient  had  an  inoperable  suppurating  carcinoma  of 
the  groin,  and  was  transfused  on  three  separate  occasions  from  five 
different  donors.  The  hemolysis  began  to  appear  on  the  second  day 
after  the  third  transfusion  (from  two  donors).  Death  occurred  ten 
days  after  this  transfusion.  After  the  previous  transfusions  there  had 
been  no  gross  evidences  of  hemolysis,  although  no  tests  were  made 
to  determine  whether  any  hemolysis  occurred  or  not.  The  question 
is  whether  death  was  due  to  hemolysis  in  the  broader  and  more  cor- 
rect sense  (i.  e.,  from  toxemia),  whether  hemolysis  would  have 
occurred  if  the  two  donors  had  been  used  on  separate  occasions  instead 
of  one  immediately  after  the  other,  whether  transfusion  from  either 
of  the  donors  alone  would  have  caused  hemolysis,  and  whether  death 
was  due  to  hemolysis  (toxemia)  caused  by  the  action  of  the  cancer 
element  in  the  serum  on  the  blood  from  the  donor. 

It  is  impossible  to  say  whether  death  occurred  from  hemolysis 
(toxemia  from  the  transfused  serum)  alone  or  from  a  combination 
of  causes.  The  patient  was  more  or  less  septic  from  the  presence  of 
infection  in  the  ulcerated  cavity  in  the  groin.     He  had  had  a  long  and 


TREATMENT   OF   SHOCK  257 

severe  illness,  the  bleeding  before  the  transfusion  was  unusually  severe, 
and  while  the  blood  lost  was  more  than  replaced  it  was  a  severe  test 
of  his  strength  and  endurance.  The  cancer  was  hopelessly  inoper- 
able and  had  progressed  well  along  toward  the  terminal  stage.  There 
had  been  no  appreciable  hemolysis  after  the  other  transfusions,  and 
in  several  other  cases  patients  had  received  blood  from  different 
donors  without  its  occurring.  It  is  known  that  cancer  serum  will 
hemolyze  red  corpuscles,  and  the  hemolysis  may  simply  have  been  due 
to  the  complete  destruction  of  the  corpuscles  from  the  donor  (the 
patient's  blood  must  have  been  very  largely  substituted  by  the  trans- 
fused blood)  without  toxin  formation  which  would  affect  any  of  the 
patient's  cells  (they  were  already  more  or  less  immune  to  the  toxin 
liberated  from  the  cancer).  On  the  other  hand,  in  patients  in  the 
last  stages  of  cancer  the  author  has  found  that  a  "  reverse  hemolysis  " 
occasionally  occurs — i.  e.,  that  the  red  cells  from  the  cancer  patient 
are  hemolyzed  by  normal  serum.  That  death  was  not  due  to  asphyxia 
from  destruction  of  the  red  corpuscles  was  shown  by  the  fact  that 
there  were  no  symptoms  before  death  which  suggested  asphyxia.  The 
probability  is  that  death  was  really  due  to  a  combination  of  factors 
which  cannot  be  separated  to  estimate  the  exact  influence  of  each. 
This  case  suggested  the  hemolysis  test  for  cancer. 

If  it  is  found  by  the  preliminary  tests  that  the  red  corpuscles  of 
the  recipient  are  hemolyzed  by  the  serum  of  the  would-be  donor,  the 
advisability  of  transfusion  should  be  carefully  considered.  This  does 
not  necessarily  indicate  that  the  blood  of  the  donor  is  at  fault,  but 
rather  that  the  recipient  is  in  such  a  condition  that  any  blood  would 
be  toxic  to  him  when  introduced  into  his  circulation.  In  all  cases 
which  the  author  has  had  there  has  been  no  evidence  that  the  blood 
of  the  donor  was  ever  at  fault.  Therefore  it  is  improbable  that  it 
would  avail  in  such  a  situation  as  the  above  to  try  to  use  another 
donor.  This  is  not  meant  to  convey  the  impression  that  the  blood  of 
the  donor  may  never  be  harmful  in  itself — in  time  donors  may  be  found 
to  whom  the  causation  of  harm  may  be  traced.  So  far,  however,  this 
has  not  been  done.  On  the  other  hand,  if  the  serum  of  the  recipient 
hemolyzes  the  red  corpuscles  of  the  donor,  it  does  not  necessarily  mean 
that  another  donor  should  be  chosen.  It  all  depends  on  whether  the 
effective  principle  or  principles  of  the  serum  are  altered  at  the  same 
time  that  the  red  corpuscles  are  destroyed. 

Following  a  successful  transfusion  certain  phenomena  almost 
always  occur.  The  stimulating  effects  of  the  new  blood  may  be  very 
marked.  A  poor  surgical  risk  may  be  made  a  good  one,  the  delirium 
of  extreme  hemorrhage  or  of  toxemia  may  be  replaced  by  a  return  to 


258  SHOCK  AND   SECONDARY  HEMORRHAGE 

normal  mental  conditions,  or  the  wrinkled,  aged  face  of  prolonged 
hemorrhage  may  be  restored  to  its  normal  aspect  and  the  years  appar- 
ently fall  away  under  the  very  eyes  of  the  observer. 

A  chill  of  greater  or  less  severity  followed  by  a  corresponding 
febrile  reaction  is  to  be  expected,  and  usually  occurs.  Former  writers 
have  often  commented  on  this  phenomenon.  It  is  not  necessarily  an 
indication  of  hemolysis,  although  a  violent  chill  is  apt  to  follow  trans- 
fusion of  dissimilar  blood.  Ordinarily  it  apparently  has  no  more  sig- 
nificance than  the  chill  which  frequently  follows  the  infusion  of  saline 
solution.  In  this  connection  it  is  of  interest  to  note  the  observations 
of  Debove  and  BruM,  who  found  after  giving  saline  infusion  a  rise 
of  temperature  of  1.5°  C.  (2,7°  F.)  in  19,  1°  C.  (1.8°  F.)  in  31,  and 
0.5°  C.  (0.9°  F.)  in  45  out  of  95  cases. 

The  heart  action  is  strengthened,  the  pulse  becomes  regular, 
slower,  of  higher  tension  and  better  volume,  and  the  respirations 
slower  and  less  shallow.  In  a  hemorrhage  case  the  change  in  the  due 
of  the  skin  and  mucous  membranes  may  be  very  marked,  while  the 
red  cells  and  hemoglobin  increase  in  proportion  as  shown  by  the  red 
counts.  In  a  certain  number  of  cases  the  recipient  has  vomited  a 
small  amount  of  watery,  grayish  material.  The  actual  ease  histories, 
however,  should  be  consulted  for  the  account  of  the  changes  occurring 
in  the  individual  cases. 

As  with  the  donors,  the  question  arises  as  to  how  much  blood 
should  be  transfused.  The  condition  of  the  donor  and  the  recipient 
and  the  purpose  of  the  transfusion  enter  into  this.  Here  again  very 
much  depends  on  the  judgment  of  the  surgeon.  No  definite  rules 
can  be  given.  Enough  blood  must  be  transfused  to  accomplish  as 
much  as  possible,  and  yet  too  much  must  not  be  given.  Sometimes 
in  cases  where  the  patient  does  not  suffer  from  the  loss  of  a  large 
amount  of  blood  it  seems  to  be  as  advantageous  to  transfuse  small 
as  large  amounts.  The  symptoms  of  the  recipient  give  the  best  key 
to  the  situation. 

Crile  regards  the  direct  transfusion  of  blood  as  an  exceed- 
ingly valuable  measure  in  the  treatment  of  the  problem  of  ex- 
sanguination.  Whatever  varied  conception  may  be  permissible 
from  a  biologic  or  chemical  viewpoint,  it  is  fair  to  state  that 
Crile' s  work  is  entitled  to  serious  consideration.  The  writer's 
conception  in  this  regard  is  expressed  by  the  extensive  quotation 
placed  in  this  volume. 

It  is  to  be  borne  in  mind,  however,  that  the  technic  of  the 


TREATMENT   OF   SHOCK 


259 


procedure  is  not  readily  mastered,  and  that,  if  the  measure  is 
undertaken  for  hemorrhage,  delay  or  a  possible  failure  are  ob- 
jectionable occurrences  in  this  class  of  cases.  As  far  as  shock 
from  injury  of  magnitude,  due  to  accidental  trauma  or  pro- 
longed manipulation  of  important  organs  during  an  operation,  is 
concerned,  the  writer  feels  that  the  objections  which  may  be 
brought  to  bear  against  direct  transfusion  do  not  apply  with 
equal  force  to  infusion  with  saline  solution. 

In  operating  in  well-equipped  hospitals,  the  direct  transfusion 
of  blood  has,  perhaps,  a  distinct  field  of  usefulness,  especially  if 
the  necessary  preparation  is  made  in  view  of  the  character  of 
operation  which  is  to  be  performed. 

In  private  practice  and,  indeed,  in  the  practice  of  surgeons 
who  operate  under  less  favorable  conditions  in  this  regard,  the 
measure  will  not  be  found  quite  as  serviceable.  Especially  is  this 
true  of  the  practitioner  who  does  emergency  surgery,  as  obtains 
in  the  less  populated  areas,  the  class  of  professional  man  this  work 
is  expected  to  serve  most. 


INFUSION 

The  infusion  into 
the  circulation  of  •so- 
lutions destined  to  in- 
crease blood  pressure 
is  made  either  into  a 
blood  vessel  sectioned 
at  the  site  of  the  oper- 
ation, or  into  one  re- 
motely situated  in 
some  other  portion  of 
the  body.  The  latter 
course  is  preferable, 
and  in  either  case  the 
injection  is  made  to- 
ward the  heart.  If 
the  infusion  is  made 
during   the   course   of 

the  operation,  a  vessel 
19 


Fig.  204. 


-Opening  the  Vein  with  Scalpel. 
{Bryant.) 


260 


SHOCK   AND    SECONDARY   HEMORRHAGE 


opening  into  the  wound  may  be  employed.     As  a  rule,  the  infu- 
sion is  best  made  into  the  vein  at  the  bend  of  the  elbow. 

The  instruments  required  for  the  purpose  are  shown  in  Fig. 
205.     The  various  kinds  of  cannulas  are  all  useful.     However,  in 


g    hi    J 


Fig.  205. — Instruments  Employed  rx  the  Operation  of  Ixftsiox.  a,  Scalpel. 
b.  Thumb  forceps,  c.  Scissors,  rl,  Aneurism  needle,  e,  Ordinary  dropper  with 
curved  point,  extemporaneous  cannula.  /,  Toothpick  for  same  purpose,  g,  Cooper's 
cannula,  h,  Kelly's  needle,  i,  Luckett's  cannula,  j,  Fowler's,  m,  Harris's  cannula. 
n.  Fowler's  thermometer  for  cannula,  o,  Catgut  and  silk-worm  gut.  p,  ^Needles. 
(Bryant.) 

case  of  emergency  a  curved  glass  eye  dropper  admirably  fills  the 
requirements.  The  reservoir  holding  the  solution  may  consist 
of  a  simple  fountain  syringe  or,  if  available,  one  of  the  appara- 
tuses shown  in  Fig.  206  may  be  used.  Glass  receptacles  have 
the  advantage  of  permitting  scrutiny  of  a  thermometer  sub- 
merged in  the  liquid  without  manipulation.  This  is,  however, 
not  essential.  Indeed,  in  operations  done  in  private  residences 
too  much  apparatus  becomes  cumbersome,  and,  as  a  matter  of 
fact,  a  glass  eye-dropper  and  a  sterile  fountain  syringe  are  all 
that  are  necessary  to  accomplish  the  purpose.  The  receptacle 
should  hang  about  three  feet  above  the  level  of  the  vein.     The 


TREATMENT   OF   SHOCK  261 

technic  of  the  procedure  is  simple,  a  bandage  is  tightly  placed 
about  the  limb  central  to  the  vein  to  be  opened,  and  the  vessel 
exposed  by  a  transverse  incision  (Fig.  204).  The  object  of  the 
central  compression  is  to  make  prominent  the  vein  and  render 
identification  more  easy.     However,  in  profound  shock  only  little 


Fig.  206. — Apparatus  for  Infusion.  Ordinary  fountain  syringe.  Kelly's  apparatus. 
Graduated  glass  reservoir  and  infusion  tube.  Fowler's  apparatus  with  thermometer 
attached.      {Bryant.) 

will  -be  achieved  as  the  result,  for  obvious  reasons.  After  cleans- 
ing of  the  skin  the  vein  is  exposed  as  stated,  and  after  isolating 
it  from  the  surrounding  tissues  a  catgut  ligature  is  passed  round 
the  vessel  and  left  untied.  Care  must  be  taken  not  to  puncture 
the  vein  at  this  time.  The  vein  is  now  ligatured  by  a  second 
catgut  ligature  placed  distally.  The  vein  is  opened  by  a  trans- 
verse incision  made  through  one-half  its  circumference,  with  scis- 
sors (Fig.  207),  and  the  cannula  is  introduced,  permitting  the 
fluid  to  flow  as  the  anastomosis  is  being  made,  to  obviate  the  en- 
trance of  air  into  the  circulation.  The  loose  ligature  is  now  tied 
with  a  half  knot  about  the  inserted  cannula  and  the  fluid  al- 
lowed to  enter.  After  the  infusion  is  completed,  the  cannula  is 
withdrawn  and  the  encircling  ligature  firmly  tied  by  completing 
the  knot,  and  the  superficial  wound  is  approximated  with  one  or 
two  sutures  and  dressed  in  the  usual  way.  The  temperature  of 
the  fluid  should  be  about  118°  F.  Various  mixtures  consisting 
of  the  inorganic  constituents  of  the  blood  in  solution  have  been 


262 


SHOCK  AND   SECONDARY   HEMORRHAGE 


employed  for  the  purpose.  However,  a  solution  composed  of  six 
parts  of  sterile  table  salt  to  one  thousand  parts  of  filtered  sterile 
water  fully  answers  the  purpose.  This  corresponds  practically 
to  a  heaped  teaspoonful  of  salt  to  a  quart  of  water. 

The  dosage  of  fluid  administered  should  be  between  one  pint 


Fig.  207. — Introducing  the  Tube  in  Infusion.     (Bryant.) 

and  a  quart,  according  to  the  indications,  given  very  slowly.  A 
quart  of  solution  should  be  injected  in  about  half  an  hour,  as  too 
rapid  instillation  is  likely  to  cause  edema  of  the  lungs  and  thus 
increase  embarrassment  to  the  circulation.  The  salt  should,  if 
feasible,  be  chemically  pure,  for  obvious  reasons,  and  the  con- 
centrated solution  described  (page  81)  is  recommended  for  use. 
A  formula  much  employed  in  hospitals  is  added. 

I£      Sterilized  and  filtered  water 32  oz. 

Sodium  chlorid  (c.  p.) 1^  drms. 

Sodium  carbonate  (c.  p.) 15  grs. 

M.    Heat  to  112°  F. 


TREATMENT  OF   SHOCK  263 

In  large  institutions  where  facilities  for  sterilization  are  con- 
veniently at  hand,  this  solution  is  made  and  kept  in  stock  to  be 
heated  at  each  operation. 

To  the  salt  solution  adrenalin  chlorid  solution  may  be  added. 
Its  prompt  action  when  administered  in  this  way  recommends  its 
use.  A  teaspoonful  of  the  adrenalin  solution  on  the  market  added 
to  a  quart  of  saline  solution  gives  the  proper  proportion  of  dilu- 
tion. The  adrenalin  may  be  added  to  the  salt  solution  when 
administered  under  the  skin  or  introduced  into  the  lower  bowel. 

NEEDLING  OF  ARTERY 

Daivbarn  in  urgent  cases  employs  a  method  called  "  needling." 
The  solution  prepared  as  above  is  placed  in  a  receptacle,  which, 
however,  must  be  elevated  to  the  height  of  six  feet  above  the  pa- 
tient, or  a  Davidson  syringe  is  used  to  inject  the  fluid.  The 
needle  of  an  ordinary  hypodermic  syringe  of  large  caliber  is 
pushed  into  the  radial  or  femoral  artery,  according  to  which  is 
the  most  available,  and  the  fluid  is  permitted  to  enter  through  a 
rubber  tube  connection.  This  method  is  useful,  but  is  only  ap- 
plicable in  cases  of  emergency,  and  should  be  used  only  by  the 
surgeon  who  has  confidence  in  his  tactile  sense.  As  a  rule,  the 
eye  is  more  trustworthy  than  the  sense  of  touch,  and  the  intra- 
venous infusion  had  best  be  employed  unless,  indeed,  the  condi- 
tions warrant  indulgence  in  the  more  intricate  manipulation. 
If  the  needle  does  not  enter  the  lumen  of  the  vessel,  it  will  be 
seen  to  distend  the  surrounding  tissues.  This  is  not  objection- 
able, as  will  be  seen  later.  The  needle  must  be  withdrawn  and 
re-entered  if  this  happens.  Accidental  introduction  of  air  will 
not  occur  if  the  fountain  syringe  be  used.  However,  this  is  liable 
to  happen  if  a  Davidson  syringe  be  employed  for  the  purpose. 
Again,  the  fluid  in  the  syringe  is  liable  to  cool  rapidly,  but  both 
the  too  rapid  cooling  of  the  fluid  and  the  entrance  of  air  may  be 
avoided  by  submerging  the  syringe  in  a  hot  solution  of  salt  while 
making  the  injection. 

HYPODERMOCLYSIS 

Hypodermoclysis  consists  of  the  injection  subcutaneously  of 
the  solution  stated.     Adrenalin  may  be  added  to  the  solution  in 


264 


SHOCK   AND   SECONDARY    HEMORRHAGE 


the  same  way  as  when  the  agent  is  used  in  intravenous  infusion. 
The  method  is  not  of  distinct  service  in  shock  from  loss  of  blood, 
except  inasmuch  as  it  contains  the  adrenalin.  Absorption  from 
beneath  the  skin  is  necessarily  slow,  and,  indeed,  it  is  a  question 


Fig.  208. — Hypodermoclysis. 


if  it  be  as  rapid  as  obtains  from  the  colon.  As  a  whole,  it  seems 
fair  to  say  that  it  is  the  less  frequently  indicated  of  the  three 
methods  of  introducing  saline  solution.  The  solution  is  placed  in 
any  one  of  the  containers  mentioned,  which  is  connected  with  a 
large-sized  needle,  and  the  skin,  after  being  cleansed,  is  punc- 
tured, and  the  fluid  slowly  permitted  to  enter.  The  pectoral  re- 
gion, the  buttocks,  and  the  lastimus  dorsi  are  favorite  sites  of 
injection.  No  more  than  half  a  pint  should  be  introduced  in 
one  place.     The  skin  will  be  found  quite  tense  as  the  outcome  of 


TREATMENT   OF   SHOCK  265 

the  entrance  of  this  quantity,  and  the  injection  of  a  greater 
amount  may  lead  to  pressure  necrosis  of  the  surrounding  soft 
parts.  Indeed,  this  possibility,  even  with  proper  precautions,  is 
sufficiently  liable  to  occur  to  constitute  an  objection  to  the  method. 
When  it  is  borne  in  mind  that  circulation  is  necessary  to  absorp- 
tion, it  is  easy  to  see  how  the  fluid  may  remain  in  the  region  of 
its  introduction  without  entering  the  circulating  fluid  for  a  con- 
siderable period  of  time.  In  cases  of  moderate  shock  not  attended 
with  loss  of  blood  the  method  may  be  used.  But  if  the  intent  of 
the  act  be  to  furnish  a  circulating  medium  to  a  depleted  periph- 
eral circulation,  the  measure  may  be  said  to  fail  to  accomplish  the 
purpose.  Fig.  208  shows  the  method  being  employed  in  the  re- 
gion of  the  pectoral  muscle.  The  needle  is  usually  steadied  by 
the  hand.  The  temperature  of  the  fluid  should  be  about  110°  F. 
At  times  a  half  hour  is  expended  in  making  the  injection.  Mas- 
sage of  the  parts  immediately  subsequent  to  the  injection  favors 
absorption  of  the  fluid. 

ENTEROCLYSIS 

Enteroclysis  means  the  introduction  of  saline  solution  into  the 
lower  bowel.  Its  rationale  as  regards  absorption  lies  in  the  as- 
sumption that  the  blood  is  more  largely  collected  in  the  vessels 
of  the  abdomen,  and  that,  because  of  this,  it  will  readily  take  up 
the  fluid.  Enteroclysis  probably  occupies  a  position  between  ve- 
nous infusion  and  injection  into  the  subcutaneous  tissue.  In  a 
general  way,  profound  shock  calls  for  venous  infusion,  less  se- 
vere shock  for  enteroclysis,  and  moderate  shock  without  loss  of 
blood  for  hypodermoclysis. 

As  a  rule,  the  lower  bowel  is  thoroughly  emptied  before  an 
operation  is  begun,  making  a  preliminary  cleansing  enema  un- 
necessary. However,  if  there  be  any  doubt  in  this  connection, 
the  enema  should  be  given. 

The  solution  employed  is,  in  every  respect,  similar  to  the  one 
used  for  intravenous  infusion,  except  that  the  quantity  which 
may  be  projected  into  the  bowel  may  be  much  greater.  Indeed, 
it  is  not  uncommonly  possible  to  introduce  a  gallon  of  the  fluid 
into  the  colon,  especially  if  the  procedure  be  slowly  accomplished. 
The  first  pint  of  the  solution  may  be  more  rapidly  introduced, 
but,  after  that,  the  bowel  is  less  likely  to  rebel  and  eject  the  fluid 


266 


SHOCK  AND   SECONDARY  HEMORRHAGE 


if  the  rest  of  the  solution  be  permitted  to  flow  into  the  colon 
slowly.  At  the  beginning  of  the  injection  the  container  may  be 
elevated  to  the  height  of  three  feet  above  the  patient,  but  after  a 
pint  has  flowed  into  the  bowel  the  irrigator  should  be  lowered  a 
full  foot.  At  no  time  should  the  pressure  be  made  greater  than 
obtains  from  three  feet  of  elevation  of  the  container. 

The  solution  need  not  necessarily  be  absolutely  sterile,  though 
this  is  desirable,  but  if  it  be  given  by  persons  not  familiar  with 
the  technic  of  asepsis,  this  method  is  vastly  superior  to  the  former 
two,  as,  of  course,  these  require  rigid  asepsis. 

The  patient  is  placed  on  the  left  side  and  the  foot  of  the  bed 
elevated  to  promote  gravity  (Fig.  209)  ;  a  rectal  tube  (Fig.  82) 


Fig.  209. — Administration  of  Saline  Solution  into  Rectum. 


is  carefully  passed  through  the  anus  and  on  into  the  sigmoid  and 
connected  with  the  rubber  tube  of  the  receptacle  by  means  of  a 
glass  tube.  The  fluid  is  then  allowed  to  flow  as  stated.  Adre- 
nalin or  other  remedial  agents  may  be  added  to  the  solution.  In- 
deed, if  a  previous  history  of  alcoholism  be  obtained,  the  bro- 


SECONDARY   HEMORRHAGE   FOLLOWING   OPERATIONS     267 

mids,  etc.,  may  be  given  at  the  same  time.  In  the  case  of  much 
nervous  irritation  preceding  the  operation,  the  writer  frequently 
adds  bromid  and  chloral  to  the  enema  with  the  view  of  obviat- 
ing the  necessity  for  the  use  of  ojnates.  These,  however,  are 
not  to  be  employed  in  cases  where  their  depressing  effect  upon 
the  circulation  is  a  consideration  of  importance. 

In  this  connection  attention  may  be  called  to  the  beneficial 
effect  produced  by  enteroclysis  with  large  quantities  of  fluid  for 
the  relief  of  thirst  following  postoperative  vomiting.  This  will, 
however,  be  more  largely  taken  up  later  (page  283). 

If  the  bowel  shows  evidence  of  irritation  and  rebellion  during 
the  administration,  the  enema  must  be  arrested.  In  these  cases 
it  is  best  to  give  a  pint  of  the  fluid  every  hour  or  two,  though  if 
a  larger  quantity  is  retained,  the  manipulation  need  not  be  re- 
peated more  frequently  than  at  intervals  of  four  to  six  hours. 

SECONDARY  HEMORRHAGE   FOLLOWING  OPERATIONS 

Bleeding  does  not  occur  during  profound  shock.  This  is  easy 
to  understand  when  the  mechanism  of  shock  is  borne  in  mind, 
and  applies  with  greater  force  to  shock  from  loss  of  blood,  which 
requires  no  stretch  of  the  imagination  to  be  regarded  as  a  con- 
servatism on  the  part  of  nature.  Shock  from  loss  of  blood  and 
spontaneous  arrest  of  hemorrhage  is  not  necessarily  the  outcome 
of  fatal  exsanguination.  The  circulatory  apparatus  conforms 
relatively  to  the  quantity  of  blood  it  contains.  If  this  be  lessened 
shock  occurs  and  the  bleeding  is  temporarily  stilled. 

The  indiscriminate  use  of  stimulants  following  severe  opera- 
tions if  large  areas  have  been  attacked  favors  the  occurrence  of 
secondary  hemorrhage.  If  all  divided  blood-vessels  have  been 
secured,  stimulants  may  be  given.  Nothing  which  raises  the 
blood-pressure  should  be  administered  if  bleeding  is  going  on. 
This  admonition  applies  especially  to  adrenalin  chlorid.  The 
routine  practice  of  giving  every  case  stimulants  as  it  comes  off 
the  table  is  to  be  deprecated  for  the  reasons  stated. 

Secondary  bleeding  occurs  simultaneously  with  reaction  from 
shock.  It  varies  in  extent  with  the  degree  of  the  shock  and  the 
quantity  of  blood  lost.  The  picture  presented  by  secondary 
hemorrhage  is  practically  that  of  shock  with  thirst  and  dyspnea 


268  SHOCK  AND   SECONDARY   HEMORRHAGE 

added.  Sudden  increase  of  pnlse  rate,  restlessness,  lowering  of 
body  temperature,  and  thirst  are  indicative  of  bleeding.  If  the 
operation  has  involved  a  cavity  which  is  subsequently  closed,  these 
manifestations  justify  measures  directed  to  the  relief  of  sec- 
ondary bleeding.  If  the  bleeding  come  from  a  superficial  wound, 
the  condition  of  the  protective  dressing  will,  of  course,  indicate 
the  bleeding  before  systemic  manifestations  present. 

The  indications  for  treatment  are  clear.  The  first  step  is  to 
arrest  the  bleeding.  The  patient  is  narcotized  and  the  bleeding 
arrested  in  the  usual  way.  Chloroform,  while  a  less  safe  agent 
in  itself,  should  be  used  for  the  purpose,  as  ether  raises  blood- 
pressure.  The  administration  of  the  chloroform  should  be  care- 
fully executed,  and  profound  narcosis  avoided  if  a  certain  mus- 
cular resistance  on  part  of  the  patient  does  not  defeat  the  object. 
When  the  bleeding  points  are  controlled,  adrenalin  chlorid  may 
be  given  hypodermatically,  and  the  field  watched  for  recurrence 
of  the  bleeding.  Hemorrhage  from  the  arteries  and  veins  is 
easily  controlled. 

Parenchymatous  oozing  and  capillary  bleeding  if  not  ar- 
rested with  hot  applications  call  for  tamponade.  The  use  of 
astringents  is  to  be  avoided. 

THE  MIKULICZ  TAMPON 

For  the  purpose  the  Mikulicz  tampon  is  exceedingly  effective. 
The  tampon  is  introduced  with  its  apex  in  the  bottom  of  the 
wound,  and  the  cavity  filled  with  strips  of  gauze  (Fig.  210). 
The  gauze  tampon  should  have  its  edges  turned  in  to  obviate  un- 
raveling, and  consists  of  four  layers  of  gauze  (Fig.  211). 

At  the  same  time  sutures  may  be  introduced  into  the  wound, 
as  shown  in  Fig.  223,  to  be  tied  when  the  tampon  is  removed. 
When  the  hemorrhage  is  arrested,  stimulants  may  be  given  and 
the  case  treated  as  described  under  shock. 

REMOVAL   OF   MIKULICZ  TAMPON 

The  Mikulicz  tampon  should  remain  in  situ  for  forty-eight 
hours.  At  the  end  of  this  time  the  gauze  strips  are  moistened 
with  a  hot  antiseptic  or  aseptic  solution,  in  the  manner  described 
under  dressing  of  wounds.      The  object  of  having  the  tampon 


SECONDARY   HEMORRHAGE  FOLLOWING   OPERATIONS     269 


Fig.  210. — Mikulicz  Tampon  in  situ.     Gauze  square  rilled  with  strips  of  gauze. 

square  in  contact  with  the  wound  surface  is  to  permit  of  removal 
of  the  bulk  of  the  pressure  agent  without  disturbance  of  the  sur- 
face of  the  wound.     The  tampon  square  is,  of  course,  adherent 


Fig.  211. — Mikulicz  Tampon.     Gauze  fashioned  into  square  with  edges  turned  in. 


Fig.  212. — Mikulicz  Tampon  Grasped  with  Heavy  Hysterectomy  Forceps 
Ready  for  Removal. 


Fig.  213. — Mikulicz  Tampon  Twisted  and  Loosened  from  Sides  of  Wound, 
Ready  to  be  Lifted  Out. 

270 


SECONDARY   HEMORRHAGE   FOLLOWING   OPERATIONS      271 

to  the  contiguous  raw  surfaces,  and  its  removal  is  likely  to  be  at- 
tended with  trauma  to  the  small  vessels,  which  have  been  ob- 
structed by  coagulated  blood,  and  when  these  clots  are  torn  away 
as  the  tampon  is  removed  renewed  hemorrhage  may  occur.  After 
the  gauze  strips  have  been  withdrawn,  hydrogen  peroxid  is 
syringed  beneath  the  edge  of  the  square  of  gauze,  and  after  the 
more  externally  located  portions  are  thus  loosened,  the  protrud- 
ing part  is  folded  together  and  held  in  a  clamp  (Fig.  212)  and 
slowly  and  carefully  twisted  (Fig.  213),  at  the  same  time  con- 
tinuing the  injection  of  hydrogen  peroxid  until  the  tampon  is 
finally  lifted  from  its  seat. 

The  solutions  used  for  the  purpose  should  be  hot  (110°  F.) 
with  the  view  of  arresting  whatever  oozing  may  occur.  The 
wound  may  now  be  closed  with  stitches  previously  introduced 
(Fig.  223),  or  be  left  open  as  the  conditions  presented  indicate. 


CHAPTER    XII 

VOMITING   AND   ACUTE   DILATATION   OF  STOMACH 

AND  GUT 

Postoperative  vomiting:  Character  of  vomited  matter — Acute  dilatation  of  the 
stomach  and  gut :  Treatment. 

POSTOPERATIVE  VOMITING 

The  postoperative  care  of  patients  varies  in  certain  regards 
with  the  character  of  affliction  for  which  the  operative  relief  has 
been  employed,  and  these  variations  will  be  taken  up  in  connec- 
tion with  the  various  classes  of  operations.  There  are,  however, 
certain  general  considerations  which  apply  with  but  little  modi- 
fication to  all  cases.  The  factor  which  enters  most  largely  into 
consideration  of  vomiting  after  operations  is  the  outcome  of  an- 
esthesia produced  by  narcotics.  The  prophylaxis  involved  in 
this  proposition  with  regard  to  restrictions  of  diet,  catharsis, 
etc.,  has  already  been  discussed  under  the  head  of  preparation 
of  the  patient  (page  38).  Beyond  this,  however,  various  medic- 
inal agents  have  at  intervals  been  more  or  less  actively  ex- 
ploited, which,  when  administered  before  the  operation,  are  be- 
lieved to  have  a  beneficial  effect  in  this  connection.  It  is  probable 
that  none  of  these  is  effective  in  all  cases,  and  that  some  have  no 
influence  in  any.  This  subject  is  taken  up  to  a  considerable  ex- 
tent in  dissertations  upon  narcosis  generally,  and  does  not  call  for 
detailed  consideration  here. 

It  is  to  be  borne  in  mind  that  the  gastrointestinal  canal  is  an 
important  eliminative  organ  when  toxic  substances  are  present  in 
the  blood,  and  it  is,  of  course,  certain  that  the  physiological  effect 
of  narcotics  is  the  outcome  of  a  poisoning  of  the  circulating  fluid 
which  is  in  no  small  degree  similar  to  toxemia  from  other  causes. 
The  vomiting  following  administration  of  narcotics  by  inhalation 
may  be  regarded  as  physiological,  though,  indeed,  the  major  por- 

272 


POSTOPERATIVE   VOMITING  273 

tion  of  the  offending  substance  is  thrown  off  by  the  lungs,  kid- 
neys, and  skin.  The  fact  that  vomiting  after  operations  is  not  in 
any  sense  dependent  solely  upon  the  operation,  is  shown  in  in- 
stances where  narcosis  is  produced  for  the  purpose  of  making  ac- 
curate physical  examinations.  In  these  instances  vomiting  fol- 
lows in  as  large  a  number  of  cases  as  obtains  when  operations 
have  been  done,  although,  be  it  also  said,  the  length  of  time  or  the 
quantity  of  narcotic  given  bears  a  direct  proportion  to  the  severity 
of  the  vomiting. 

Perhaps  the  measure  which  is  most  largely  employed  is  the 
administration  hypodermically  of  one-quarter  of  a  grain  of  mor- 
phia and  one-one  hundredth  of  a  grain  of  atropia  one  hour  before 
the  operation.  This  measure  has  been  universally  useel  by  sur- 
geons, and  if  not  always  effective  with  regard  to  the  control  of 
vomiting,  has  some  additional  advantages  which  make  justifiable 
its  employment. 

In  the  vast  majority  of  instances  the  mental  status  of  a  pa- 
tient about  to  be  subjecteel  to  surgical  operation  is  apprehensive, 
and  the  small  close  of  morphia  mentioned  creates  a  certain  com- 
placency of  mind  which  is  not  objectionable.  The  atropin  is  also 
slightly  stimulating,  and  its  effect  ujdoii  the  salivary  secretions  is 
beneficial,  as  it  lessens  the  quantity  of  saliva  and  mucous  secre- 
tion in  the  mouth  and  in  a  measure  prevents  excessive  collection 
of  fluids  in  the  air  passages  during  the  narcosis.  On  general  prin- 
ciples, it  is  difficult  to  see  how  morphia,  which  paralyzes  involun- 
tary muscular  fibers  and  lessens  secretions  generally,  can  in  any 
way  hasten  elimination  of  the  narcotic  employed.  Indeed,  the 
contrary  is  to  be  expected,  yet  it  would  seem  that  vomiting  does 
not  occur  as  largely  in  instances  where  this  mixture  of  morphia 
and  atropia  has  been  given.  The  writer  does  not  employ  medic- 
inal agents  before  operations  with  the  notion  of  controlling 
vomiting,  for  the  reasons  stated,  though  in  especial  cases  and  for 
special  indications  the  mixture  mentioned  is  in  a  certain  num- 
ber of  cases  employed. 

In  a  few  instances  postoperative  vomiting  is  maintained  for 
many  hours,  and,  indeed,  for  days  after  operation.  This  will, 
however,  be  found  to  be  the  result  of  the  character  of  operation, 
the  coexistence  of  nephritis,  or  due  to  a  toxemia  other  than  the 
effect  of  the  narcotic.     In  every  case  in  which  vomiting  persists 


274     VOMITING  AND  ACUTE  DILATATION  OF  STOMACH  AND  GUT 

for  more  than  several  hours  following  an  operation  these  factors 
must  be  considered.  Few  agents  remain  in  the  circulation  for 
many  hours  after  administration,  and  when  it  is  remembered 
that  narcotics  enter  the  circulation  through  the  respiratory  tract, 
and  are  not  gradually  absorbed  from  the  stomach,  as  is  the  case 
when  medicinal  agents  are  administered,  the  rationale  of  this^ 
statement  seems  clear.  This  means  that  toxemia  due  to  sub- 
stances in  the  stomach,  or  one  which  is  the  outcome  of  an  avail- 
able reservoir  in  the  form  of  an  area  of  inflammation,  presents  the 
picture  of  a  disturbed  balance  between  absorption  and  elimina- 
tion, while  the  source  of  supply  is  immediately  withdrawn  when 
no  more  narcotic  is  administered,  and  last  it  is  worthy  of  note 
that  narcotics  are,  because  of  their  chemical  and  physical  char- 
acteristics, very  rapidly  thrown  off. 

Assuming  that  the  stomach  is  concerned  in  eliminating  these 
agents,  it  is  not  difficult  to  conceive  of  a  mixture  of  mucus  and 
secretion  in  the  stomach,  which  holds  the  end  products  of  the  nar- 
cotic in  solution  or  in  suspension,  and  that  a  liberal  evacuation 
of  this  is  desirable.  In  order  to  accomplish  this,  many  surgeons 
administer  a  pint  of  warm  saline  solution  to  patients  as  soon 
after  the  operation  as  deglutition  is  possible,  and  regard  the  re- 
sultant evacuation  of  the  stomach  as  eliminative  and,  perhaps, 
less  offensive  and  objectionable  than  gastric  lavage  at  this  time. 
Also,  for  the  same  reasons,  lavage  of  the  stomach  is  done  at  times 
on  the  operating  table  while  the  patient  is  still  narcotized.  How- 
ever, it  is  to  be  remembered  that  the  actual  indication  for  this 
measure  does  not  occur  until  the  stomach  has  been  for  several 
hours  concerned  in  eliminating  the  narcotic,  and  that  perhaps 
the  only  benefit  which  immediate  lavage  may  accomplish  is  re- 
moval of  the  contents  accumulated  during  the  operation,  and 
perhaps,  too,  it  may  be  regarded  as  preparing  the  gastric  mucosa 
better  for  its  impending  labor.  Following  operations  upon  the 
upper  air  passages,  in  which  instances  blood  and  secretions  are 
inadvertently  swallowed  by  the  patient,  an  especial  indication  for 
immediate  gastric  lavage  is  presented,  and  the  measure  is  prop- 
erly employed  at  this  time. 

While  the  stomach  is  concerned  in  this  eliminative  function 
it  is  quite  incapable  of  converting  nutritive  substances  into  ab- 
sorbable material  ready  for  entrance  into  the  circulating  fluid, 


POSTOPERATIVE   VOMITING  275 

and,  therefore,  the  introduction  of  articles  of  diet  during  the  first 
few  hours  immediately  following  the  operation  is  contraindi- 
cated.  Indeed,  these  substances  when  introduced  accumulate  in 
the  stomach  and  act  as  a  foreign  body,  which  increases  the  irri- 
tation of  the  gastric  mucosa  already  present  as  the  outcome  of 
its  eliminative  efforts,  and  prolongs  vomiting.  For  this  reason  it 
is  the  rule  to  rest  the  stomach  completely  as  regards  digestive  ef- 
forts for  twelve  hours  after  the  operation.  This  does  not  mean 
that  the  narcotic  is  not  eliminated  before  the  expiration  of  the 
twelve  hours,  but  that,  unless  lavage  or  vomiting  has  cleansed  the 
stomach,  the  condition  of  the  mucosa  is  such  as  to  render  normal 
function  of  the  organ  quite  impossible. 

The  causative  factors  which  enter  into  gastric  disturbances 
following  operations  do  not  relate  alone  to  the  narcosis.  Indeed, 
it  may  be  said  that,  while  this  is  an  important  consideration,  its 
consequences  are  most  largely  questions  of  comfort  and  expe- 
diency in  recovery.  The  fatal  disturbances  of  the  stomach  which 
are  at  times  attributed  to  the  carelessness  of  the  nurse  or  attend- 
ant in  administering  food  or  medication  immediately  after  an 
operation  are  the  outcome  of  much  graver  influences  than  this. 

It  is,  of  course,  best  not  to  permit  of  the  administration  of 
any  food  for  the  time  stated.  Yet,  the  introduction  of  small 
quantities  of  hot  water,  a  teaspoonful  every  fifteen  minutes,  is 
not  objectionable,  and  acts  as  a  diluent  to  the  offensive  material 
in  the  stomach  and,  indeed,  in  its  passage  over  the  pharyngeal  and 
esophageal  mucosa  is  exceedingly  grateful  to  the  patient.  The 
water  is,  of  course,  not  destined  to  relieve  thirst  by  its  local 
action,  as  thirst  is  a  local  manifestation  of  the  systemic  need  for 
fluids.  However,  if  has  a  certain  place  in  this  connection  and 
may  be  used.  It  may  also  be  replaced  with  cold  water  or  cracked 
ice  used  in  the  same  proportions,  if  there  be  no  contraindication. 
This  is,  however,  largely  a  matter  of  the  patient's  taste,  as  the 
temperature  of  either  is  about  the  same  at  the  end  of  the  six  sec- 
onds required  for  deglutition.  Thirst  as  a  postoperative  occur- 
rence is  taken  up  under  a  separate  head  (page  283  ). 

Summarizing  the  situation  as  so  far  presented,  it  is  fair  to 
say  that  if  vomiting  be  a  manifestly  obtrusive  symptom  at  the  end 
of  several  hours  after  operation,  a  pint  of  warm  saline  solu- 
tion may  be  given,  and  if  this  be  ineffectual  in  controlling  the 
20 


276    VOMITING  AND  ACUTE  DILATATION  OF  STOMACH  AND  GUT 

vomiting,  gastric  lavage  may  be  employed.  In  any  event,  the 
various  medicinal  agents  which  are  quite  generally  regarded  as 
capable  of  affording  relief  are  best  omitted.  Rest,  as  far  as  the 
digestive  function  of  the  stomach  is  concerned,  is  the  wisest  plan 
to  pursue.  A  direct  local  effect  from  these  agents  upon  the 
gastric  mucosa  is  difficult  to  understand,  and  if  the  action  of  the 
agent  be  regarded  as  the  outcome  of  entrance  into  the  circula- 
tion, and  general  effect  is  designed,  the  hypodermic  method  and 
the  lower  bowel  present  far  more  favorable  avenues  of  approach 
than  is  obtained  as  the  outcome  of  deglutition. 

The  introduction  of  medicinal  and  nutritive  agents  into  the 
rectum  is  taken  up  under  a  separate  head  (page  291). 

CHARACTER   OF   VOMITED   MATTER 

This,  aside  from,  the  indications  it  gives  of  diagnostic  value, 
is  of  great  prognostic  import,  and  in  every  case  the  nurse  or  at- 
tendant must  be  instructed  to  preserve  the  vomit  for  inspection, 
and,  indeed,  in  some  instances  microscopical  examination  should 
be  employed  to  clear  up  doubtful  conclusions  in  this  connection. 
Neglect  of  this  precaution  may  result  in  a  fatal  outcome  which 
perhaps  might  have  been  avoided. 

The  presence  of  even  minute  particles  of  blood,  as  shown  by 
small  dark  streaks  in  the  vomit,  always  arouses  alarm.  If  the 
vomiting  is  repeated,  and  there  be  an  increased  quantity  of  the 
suspicious  color,  the  case  may  be  regarded  as  either  one  of  dila- 
tation of  the  stomach  or  a  beginning  sepsis.  The  former  is  most 
likely  to  occur  within  twenty-four  or  thirty-six  hours  following 
the  operation,  and  calls  for  appropriate  treatment  at  once.  When 
the  vomit  is  due  to  sepsis,  it  does  not  usually  occur  until  after 
the  second  day  following  the  operation,  unless  already  an  over- 
whelming sepsis  has  existed  at  the  time  of  the  operation. 

In  the  latter  event,  the  evidence  of  sepsis  will  be  manifest  at 
the  time,  and  the  vomit  of  blood  will  not  be  likely  to  cause  con- 
fusion as  to  its  origin.  Following  abdominal  operations  for  the 
relief  of  infective  processes,  such  as  pyosalpinx,  suppurative 
cholecystitis,  or  appendicitis  with  abscess,  the  appearance  of 
blood  in  the  vomit  may  readily  be  regarded  as  evidence  of  sys- 
temic invasion  of  the  septic  process,  the  outcome  of  liberation  of 
infectious  material  into  the  contiguous  peritoneum. 


ACUTE  DILATATION   OF  THE  STOMACH  AND   GUT  277 

However,  in  a  certain  number  of  cases  the  bloody  vomit  is  the 
outcome  of  an  acute  dilatation  of  the  stomach  and  gut  due  to 
either  shock,  the  narcotic,  or  the  mauling  of  the  abdominal  or- 
gans during  the  surgical  manipulations.  Especially  is  this  true 
with  respect  to  attack  upon  the  gall-bladder.  In  these  cases,  the 
position  of  the  patient  making  more  accessible  the  operative  field, 
the  interference  with  respiration,  the  outcome  of  delivery  of  the 
liver  into  the  wound,  contributes  not  a  little  to  the  general  dis- 
turbance, resulting  not  infrequently  in  acute  dilatation  of  the 
stomach  and  gut.  Indeed,  in  this  class  of  cases  the  stomach  it- 
self is  handled  to  a  greater  or  lesser  extent,  depending  upon 
whether  the  common  duct  is  attacked,  and  the  trauma  to  the  py- 
lorus contributes  a  not  unimportant  part  to  the  outcome.  The 
condition  is  more  frequently  a  postoperative  complication  follow- 
ing abdominal  operations  than  after  operations  in  other  portions 
of  the  body,  a  fact  which  would  tend  to  show  a  certain  causative 
relationship  in  the  connection  mentioned. 

ACUTE   DILATATION   OF   THE   STOMACH   AND    GUT 

Acute  dilatation  of  the  stomach  and  gut  occurs  with  suffi- 
cient frequency  after  operations  to  warrant  consideration  here. 

The  condition,  is  perhaps  well  represented  in  the  history  of 
the  case  here  described. 

Mrs.  A.  H.,  subjected  to  Cesarean  section.  Pelvis  filled  with 
immovable  mass,  which  proved  upon  celiotomy  to  be  a  large  der- 
moid cyst.  Hysterotomy  and  delivery  of  fetus  readily  accom- 
plished in  the  usual  manner.  Operation  done  with  considerable 
rapidity  was  not  attended  with  evidence  of  shock  of  sufficient  im- 
port to  call  for  the  use  of  particular  precautionary  measures.  At 
end  of  twenty-two  hours  the  patient  expressed  herself  as  feeling 
comfortable.  Temperature  in  rectum  100°  F.,  pulse  115.  Vom- 
ited at  this  time  four  ounces  of  clear  fluid  slightly  streaked  with 
blood.  Patient,  however,  was  not  permitted  to  partake  of  nour- 
ishment by  mouth.     Saline  irrigation  of  colon  ordered. 

At  the  time  of  the  operation  no  evidence  of  infection  had 
been  manifest,  and  it  was  considered  improbable  that  infection 
had  been  introduced  at  the  time  of  the  operation.  The  presence 
of  blood  in  the  vomit  was  regarded  as  accidental   and  possibly 


278    VOMITING  AND  ACUTE  DILATATION  OF  STOMACH  AND  GUT 

the  outcome  of  the  rupture  of  a  small  vessel  in  the  esophagus. 
However,  the  increase  of  pulse  rate  disproportionate  to  the  ac- 
companying symptoms  was  regarded  as  suspicious.  It  was  diffi- 
cult to  conceive  of  a  se]  sis  so  overwhelming  as  to  cause  venous 
stasis  and  hemorrhage  into  the  stomach  after  the  lapse  of  a  bare 
twenty-four  hours  following  the  operation.  Six  hours  later  the 
patient  vomited  a  pint  of  dark  brown  fluid,  which  upon  micro- 
scopical examination  proved  to  consist  largely  of  blood.  The 
pulse  rate  had  not  been  accelerated  at  this  time,  being  still  110 
to  115  per  minute.  The  temperature  had  risen  to  101°  F.,  which 
excluded  delayed  shock.  The  patient  at  this  time  expressed  her- 
self as  feeling  comfortable  and  asked  for  food. 

The  clinical  picture  was  confusing.  Sepsis  was  regarded  as 
exceedingly  improbable,  and  in  view  of  the  absence  of  symptoms 
other  than  the  bloody  vomit,  after  consultation  with  Dr.  L.  K. 
Neff,  it  was  decided  to  ask  Dr.  Robert  Coleman  Kemp  to  see  the 
case  with  the  view  of  washing  out  the  stomach,  and  to  obtain  the 
benefit  of  his  advice.  Several  hours  later,  when  Dr.  Kemp  saw 
the  case  (thirty  hours  after  the  operation),  the  abdomen  had  be- 
come distended,  the  patient  complained  of  oppression  in  the  epi- 
gastrium, dyspnea,  and  the  facial  expression  was  anxious.  Tem- 
perature, 101°  F. ;  pulse,  120.  Examination  of  the  abdomen 
showed  what  appeared  to  be  a  widely  distended  stomach,  though 
the  tympanitis  was  not  limited  to  the  region  of  the  stomach.  It 
was  evident  that  the  intestines  were  also  distended.  Dr.  Kemp 
made  immediate  gastric  siphonage,  drawing  off  a  gallon  of  dark 
brown  fluid.  The  colon  was  then  irrigated  per  rectum,  the  head 
of  the  bed  elevated,  and  eserin  and  strychnia  administered  hypo- 
dermically.  Immediately  after  the  gastric  siphonage  and  lavage 
the  distention  in  the  upper  segment  of  the  abdomen  disappeared. 
The  colic  irrigation  was  attended  with  expulsion  of  large  quan- 
tities of  gas  and  some  liquid  feces.  The  distention  in  the  lower 
portion  of  the  abdomen  was  not  so  palpably  reduced  as  had.  ob- 
tained in  the  region  of  the  stomach. 

The  patient  expressed  herself  as  much  relieved,  the  respira- 
tions became  tranquil,  and  the  pulse  rate  diminished  to  100  per 
minute.  At  the  end  of  another  six  hours  the  distention  in  the 
upper  portion  of  the  abdomen  reappeared,  though  it  was  less 
marked   than  before.      The  same  treatment  was  employed  with 


ACUTE  DILATATION   OF  THE   STOMACH  AND   GUT  279 

the  same  effect.  The  colic  lavage  was  made  continuous  from  this 
time,  employing  the  Kemp  tube  (Fig.  345)  for  the  purpose.  The 
administration  of  eserin  and  strychnia  was  repeated.  The  symp- 
toms did  not  reappear  after  this,  and  the  patient  made  an  unin- 
terrupted recovery,  although  the  pulse  rate  did  not  assume  nor- 
mal proportions  for  several  days  after  the  abdominal  symptoms 
had  subsided,  showing  that  a  serious  impression  had  been  made 
upon  the  vital  processes. 

This  case  may  be  regarded  as  typical  of  acute  dilatation  of 
the  stomach  and  intestines  following  operation  in  which  shock 
was  not  a  distinct  causative  factor,  although  the  narcosis  may 
have  to  be  considered  as  a  causative  element.  It  illustrates,  too, 
the  necessity  for  a  close  scrutiny  of  the  vomit  after  operations. 
Had  the  operation  been  undertaken  for  the  relief  of  an  intra- 
abdominal infection,  the  first  appearance  of  "  black  vomit " 
would  have  been  regarded  as  indicative  of  an  overwhelming  sep- 
sis, and  an  unfavorable  prognosis  given.  Whether  the  stomach 
would  have  been  washed  out  or  not  at  this  time  would  have  de- 
pended upon  the  conception  the  attendant  had  of  the  utility  of  the 
measure  as  a  matter  of  routine.  The  technic  of  gastric  lavage 
is  a  simple  one.  However,  its  execution  is  attended  with  con- 
siderable annoyance  to  the  patient  and  is  not  to  be  lightly  under- 
taken, especially  ^as  the  retching  and  vomiting  attendant  upon 
the  measure  are  undesirable  if  the  operation  happens  to  involve 
the  abdomen.  Fear  in  these  cases  is  felt  that  the  stitches  may 
tear  out.  The  dilatation  may  be  in  certain  cases  limited  to  the 
stomach,  and  lavage  or  siphonage  or  both  of  this  organ  may  meet 
the  indications.  However,  it  is  probable  that  in  postoperative 
cases  the  dilatation  is  not  limited  to  the  stomach,  and  an  effort 
should  be  made  to  stimulate  contraction  of  the  gut  by  copious 
colic  lavage. 

The  technic  of  gastric  lavage  need  not  be  entered  into  here. 
Indeed,  the  discussion  of  colic  lavage  or  irrigation  is  also  some- 
what out  of  place  in  a  work  of  this  sort.  It  is  regarded  proper 
by  the  writer  to  state  that  colic  lavage  is  best  made  with  a  return 
tube  in  these  cases,  and  ample  opportunity  should  be  given  for 
the  discharge  of  feces  and  gas  by  rectum. 

In  discussing  the  problem  here,  the  acute  dilatations  of  the 
stomach  consequent  to  errors  of  diet  need  not  be  considered,  ex- 


280    VOMITING  AND  ACUTE  DILATATION  OF  STOMACH  AND  GUT 

cept  inasmuch  as  it  should  be  remembered  that  probably  the  ad- 
ministration of  food  by  mouth  soon  after  operations  may  be  re- 
garded as  a  contributory  cause  of  the  condition.  The  type  of 
cases  seen  after  operation  is  what  Kemp  calls  the  mixed  type  of 
gastric  and  intestinal  dilatation.  If  it  be  true  that  shock  causes 
a  paralysis  of  the  splanchnic  and  pneumogastric  areas,  it  is  easy 
to  understand  that  dilatation  of  the  gastro-intestinal  tract  is  a 
logical  outcome  in  certain  instances.  It  is  not  to  be  assumed  that 
selective  action  is  restricted  to  the  enervation  of  the  stomach 
alone  in  these  cases,  and,  indeed,  clinically  it  is  manifest  that  the 
intestines  are  also  involved.  This  means  that  measures  of  relief 
should  not  be  restricted  to  the  stomach  alone,  as  has  already  been 
mentioned. 

Just  how  powerfully  causative  a  factor  the  narcosis  is  in  these 
cases  is  not  clear.  It  has  been  shown  that  prolonged  choloroform 
or  ether  narcosis  without  there  having  been  any  operation  per- 
formed will  result  in  acute  dilatation  of  the  stomach. 

Whether  the  causation  be  that  of  shock  or  narcosis  or  the 
excessive  manipulations  of  the  abdominal  contents,  is  not  a  mat- 
ter of  great  importance  for  the  purpose  here  considered.  In  any 
event,  it  is  certain  that  the  condition  is  the  outcome  of  a  paralysis 
of  the  muscular  coats  of  the  gastro-intestinal  canal,  and  that,  as 
the  result  of  this,  a  venous  stasis  occurs  which  causes  hemorrhagic 
infiltration  and  rupture  of  the  capillaries  in  the  mucosa.  Blood 
and  serum  are  poured  into  the  stomach  and  gut,  are  vomited  in 
the  form  of  "  black  vomit,"  and  passed  per  rectum  in  the  same 
form.  If  the  condition  be  not  relieved,  the  picture  is  one  of  de- 
gree, varying  with  whether  the  venous  stasis  goes  on  to  slough- 
ing and  perforation,  or  if  death  occurs  from  toxemia,  death  from 
the  latter  cause  occurring  in  from  a  few  hours  to  two  days  follow- 
ing the  operation. 

TREATMENT 

The  treatment  of  the  condition  is  quite  indicated  in  the  report 
of  the  case  mentioned.  In  addition  to  this,  the  shock  treatment 
is  to  be  employed  and  eserin  and  strychnia  given,  the  latter  to 
guard  the  former.  Eserin  is  given  in  doses  of  1-50  to  1-30  of  a 
grain,  and  strychnia  as  it  is  usually  used. 

Kemp,  after  cleansing  the  stomach  with  water,  to  a  quart  of 


ACUTE  DILATATION   OF  THE  STOMACH  AND   GUT  281 

which  two  ounces  of  milk  of  magnesia  has  been  added,  puts  into 
the  stomach  through  the  tube  three  to  five  grains  of  calomel,  to- 
gether with  an  ounce  of  water.  The  lavage  is  repeated  in  two 
hours.  It  is  best  to  err  on  the  side  of  frequency  in  washing. 
The  fact  that  the  patient  does  not  vomit  cannot  be  regarded  as 
indicative  of  a  favorable  condition  of  affairs.  The  degree  of 
distention  and  discomfort  is  the  best  indication  as  to  the  condi- 
tions. Indeed,  when  the  patient  vomits,  the  symptoms  are  less 
apt  to  become  alarming,  for  very  obvious  reasons.  Eserin,  to- 
gether with  strychnia,  has  already  been  considered.  The  colic 
lavage  is  repeated  as  often  as  necessary.     Indeed,  this  measure 


Fig.  214. — Postural  Treatment  for  Acute  Dilatation  of  Stomach  and 
Intestine,  Following  Operation. 

has  so  many  allied  advantages  that  it  may  be  used  to  a  consid- 
erable extent. 

The  postural  treatment  is  regarded  as  exceedingly  useful. 
The  patient  is  postured  in  a  semi-oblique  position  by  raising  the 
head  of  the  bed  (Fig.  214).  The  benefit  from  this  is  ascribed 
to  the  fact  that  the  abdominal  contents  are  encouraged  to  gravi- 
tate away  from  the  thoracic  organs.     The  posture  is,  of  course, 


282    VOMITING  AND  ACUTE  DILATATION  OF  STOMACH  AND  GUT 

not  quite  so  favorable  to  the  entrance  of  the  colic  lavage  fluid, 
but  as  the  intent  of  this  is  to  facilitate  discharge  of  the  intestinal 
contents,  the  position  may  be  considered  beneficial  in  this  con- 
nection. On  the  whole,  the  cleansing  of  the  stomach  and  the 
colic  lavage  are  the  measures  which  achieve  the  greatest  amount 
of  good. 


CHAPTER    XIII 
THIRST  AND    PAIN 

Thirst:  Treatment  of  thirst — Pain 

THIRST 

Thirst  is  one  of  the  most  distressing  symptoms  following  se- 
vere operations.  It  bears  a  quite  direct  proportion  to  the  quan- 
tity of  blood  lost  and  the  amount  of  fluids  expelled  with  the 
vomit.  Given  a  prolonged  operation,  attended  with  considerable 
loss  of  blood  and  followed  by  severe  vomiting  of  irritating  fluids, 
as  frequently  obtains,  and  the  conditions  present  a  picture  which 
the  practitioner  often  faces,  while  the  operator  goes  on  his  way 
with  the  complacency  born  of  the  belief  that  he  has  done  a  skill- 
ful operation.  Indeed,  it  is  in  these  cases  that  the  practitioner 
is  tempted  to  employ  the  various  medicinal  agents  already  al- 
luded to  in  connection  with  postoperative  vomiting. 

As  a  rule,  the  patient  bears  a  different  relationship  to  the 
practitioner  than  that  which  obtains  toward  the  surgeon,  and  the 
former  is  appealed  to,  and,  indeed,  often  enough  pitifully  im- 
plored to  do  something  to  afford  relief. 

TREATMENT   OF  THIRST 

Opiates,  for  obvious  reasons,  increase  thirst.  The  indication 
is  to  supply  fluids  to  the  circulation.  The  introduction  of  fluids 
into  the  stomach  provokes  vomiting  and  increases  thirst.  It  is 
in  these  cases  that  copious  colic  lavage  is  of  the  greatest  service. 

The  technic  of  its  employment  is  in  all  respects  similar  to 
that  employed  in  shock.  Salt  is  added  to  obviate  extraction  of 
inorganics  from  the  epithelium  of  the  colic  mucosa.  When  water 
alone  is  used,  the  cells  give  up  their  coloring  matter,  and  the  in- 
organics are  taken  up  in  solution.     Whatever  the  function  of  the 

283 


284  THIRST   AND   PAIN 

inorganics  may  be,  they  certainly  are  essential  to  metabolism, 
and  experimentation  shows  that  osmosis  of  saline  solutions  is 
more  rapid  than  obtains  with  plain  water.  It  is  generally 
regarded  that  salt  promotes  thirst.  This  may  be  true  under 
physiological  conditions,  but  for.  the  purpose  of  obtaining 
rapid  absorption  of  fluids  after  operations,  it  is  essential  to  the 
intent. 

The  lips  should  be  frequently  moistened  with  hot  water.  For 
this  purpose  the  nurse  uses  a  piece  of  cotton  soaked  with  hot 
water,  and  replaces  it  frequently  with  a  clean  portion.  Small 
doses  of  hot  water,  as  mentioned  in  connection  with  vomiting, 
may  be  swallowed  at  intervals.  If  the  vomit  be  acid,  the  burn- 
ing sensation  in  the  pharynx  and  mouth  may  be  relieved  by  al- 
lowing the  patient  to  rinse  the  mouth  with  a  solution  of  sodium 
bicarbonate.  A  small  portion  of  the  solution  is  usually  swal- 
lowed, and  the  distress  in  the  esophagus  from  the  same  cause  is 
lessened. 

If  pain  be  not  a  marked  symptom,  opiates  should  be  avoided, 
as  already  stated.  However,  if  thirst  and  restlessness  be  extreme 
and  not  relieved  by  the  measure  indicated,  morphia  should  be 
given  hypodermically  and  in  one  large  dose,  i.e.,  one-half  a  grain. 
This  will  induce  sleep  and  give  opportunity  for  the  replacement 
of  the  fluids  lost. 

Many  practitioners  add  atropin  to  the  morphin.  This  is 
inadvisable,  as  the  latter  ae'ent  dries  still  more  the  fauces.  The 
repeated  administration  of  small  doses  of  morphia  is  a  procrasti- 
nation. It  should  be  given  in  one  good-sized  dose  when  the  indi- 
cation for  its  use  is  clear.  The  use  of  codein  is  also  a  subterfuge. 
The  alkaloid  of  opium  which  is  the  most  anodyne  is  morphia, 
and  if  this  be  true,  the  employment  of  a  substitute  alkaloid  is  un- 
scientific. 

It  must  be  remembered  that  the  quantity  of  urine  excreted 
by  patients  from  whom  large  quantities  of  fluids  have  been  with- 
drawn is  largely  reduced,  and  that  catheterization  is  not  apt  to 
be  necessary  for  eight  to  ten  hours.  If  morphia  is  given,  the 
sense  of  bladder  fullness  is  likely  to  be  dulled,  and  this  must  be 
taken  care  of.  Patients  who  require  opiates  after  operations  are 
more  likely  to  require  withdrawal  of  the  urine  by  catheter  than 
if  the  drug  be  omitted. 


PAIN  285 

The  treatment  of  severe  thirst  may  be  summarized  into  the 
administration  of  a  full  dose  of  morphia  (gr.  ss)  hypodermically 
and  the  introduction  of  a  large  quantity  of  saline  solution  into 
the  rectum  or  colon.  The  morphia  should  not  be  given  unless  the 
colic  injection  is  to  be  made. 

The  morphia  will  not  enhance  the  dryness  of  the  buccal  mu- 
cosa for  about  fifteen  minutes  after  its  administration,  during 
which  time  a  considerable  quantity  of  the  saline  solution  will  have 
been  absorbed  from  the  gut.  The  picture  of  a  restless,  thirsty 
patient,  mumbling,  dry-lipped  for  water,  is  soon  replaced 
by  one  going  to  sleep,  and  the  supply  of  water  to  the  circu- 
lating fluid  goes  quietly  on  as  the  patient  sleeps.  The  writer 
has  frequently  seen  the  efficiency  of  the  measure  practically 
demonstrated. 

PAIN 

The  character,  degree,  and  persistence  of  pain  following 
operations  vary,  of  course,  with  the  kind  of  operation  and  the 
affliction  for  the  relief  of  which  it  is  undertaken.  As  a  general 
rule,  wound  pain  is  not  severe.  The  reparative  hyperemia  at- 
tendant upon  uninfected  wounds  is  not  usually  sufficiently  se- 
vere to  cause  pain. 

In  a  general  way  the  technic  of  operations  should  be  di- 
rected toward  the  avoidance  of  postoperative  pain.  This  will  be 
found  feasible  in  a  larger  number  of  instances  than  would  ap- 
pear from  a  casual  analysis  of  the  situation.  If  the  operator 
would  bear  in  mind,  as.  each  stitch  is  inserted  and  tied,  that  just 
sufficient  tension  to  hold  tissues  in  apposition  is  all  that  is  neces- 
sary to  accomplish  the  purpose,  much  postoperative  pain  would 
be  avoided.  The  objections  to  tightly  drawn  sutures  have  al- 
ready been  mentioned ;  the  warning  is  sounded  again  in  this  con- 
nection from  an  additional  viewpoint.  Buried  apparatus  of  im- 
mobilization should  be  introduced  with  the  same  factors  in  mind. 
Indeed,  a  nail  may  be  driven  into  bone  without  the  occurrence  of 
subsequent  pain,  provided  the  contiguous  tissues  be  so  repaired 
as  not  to  make  pressure  on  the  former.  The  gall-bladder  may  be 
attached  to  the  anterior  abdominal  wall  without  entailing  severe 
subsequent  suffering  to  the  patient,  provided  the  movements  of 


286  THIRST  AND   PAIN 

respiration  be  shown  proper  consideration  in  making  the  anasto- 
mosis. 

The  surgeon  is  asked  to  take  this  into  consideration  during 
the  operation,  as  a  plea  coming  from  the  attendant  taking  care 
of  the  after-treatment.  Of  course,  here  again  the  question  of 
opiates  comes  up.  And,  indeed,  here  again  the  rule  laid  down 
with  regard  to  thirst  is  to  be  applied — avoidance  of  opiates  until 
the  indication  is  clear,  and  then  the  administration  of  a  full 
dose. 

The  nurse  should  not  be  given  an  order  to  give  a  sixth  of  a 
grain  of  morphia  hypodermically  every  two  hours  until  the  pain 
is  relieved,  but  the  practitioner  had  best  give  the  full  dose  him- 
self, watch  its  effect,  and  only  repeat  it  when  again  the  indica- 
tion is  imperative.  In  the  interim  measures  for  the  more  sat- 
isfactory immobilization  of  the  tissues  subjected  to  trauma  may 
be  taken. 

Under  no  circumstances  should  opiates  be  administered  if 
pain  be  the  outcome  of  the  method  in  which  the  dressings  are  ap- 
plied. In  these  instances  the  retention  bandage  must  be  taken 
off  and  replaced.  Especially  is  this  true  when  plaster-of-Paris 
has-been  used.  If  severe  pain  occurs  in  a  non-infected  wound 
beneath  plaster-of-Paris,  it  should  be  at  once  removed.  If  in- 
fection be. present  at  the  time  of  the  operation,  plaster-of-Paris 
should  not  be  employed  unless  ample  provision  for  inspection  of 
the  wound  be  made. 

If  wounds  are  packed  with  gauze,  the  packing  should  not  be 
so  firmly  introduced  as  to  cause  pain.  A  tamponade  made  for 
the  purpose  of  arresting  hemorrhage  should  not  be  rammed  in 
with  a  director  as  though  the  intent  were  to  stop  a  leak  in  a  steam 
pipe.  It  is  only  necessary  to  bear  in  mind  that  the  normal  blood 
pressure  needs  only  to  be  overcome,  and  that  light  pressure  with 
the  finger  in  the  abdomen  readily  controls  the  flow  of  blood  in 
the  aorta.  All  that  is  necessary  is  to  fill  the  bleeding  cavity  with 
gauze  to  moderate  distention.  If  severe  pressure  is  made,  the 
meshes  of  the  gauze  are  buried  in  the  tissues,  and  when  the  gauze 
is  removed,  the  coagulum  is  torn  away  and  fresh  bleeding 
may  occur.  The  gauze  takes  no  part  in  the  repair  of  divided 
blood  vessels  and  capillaries.  These  are  obliterated  by  blood 
clot  and  later  by  scar  tissue,   and  the  gauze   sinrply   acts  as  a 


PAIN  287 

plug   until   this   lias   occurred.      Packing   in   wounds    should   not 
cause  pain. 

Still  less  necessary  is  it  to  pack  firmly  infected  wounds.  In 
these  cases  the  intent  of  the  packing  is  to  obliterate  blind  spaces 
and  cause  infective  secretions  to  find  their  way  into  the  gauze 
and  out  of  the  wound  by  capillarity.  Firm  packing  prevents 
the  intent  mechanically,  and  the  gauze  should  be  so  placed  in  the 
wound  as  to  permit  of  ready  egress  of  the  offending  material. 


CHAPTEE    XIV 
FEEDING  AFTER   OPERATION 

Feeding  by  mouth — Rectal  feeding. 

The  diet  after  operations  varies  somewhat  with  the  character 
of  operation  the  patient  has  been  subjected  to.  Variations  in  this 
regard,  arising  for  this  reason,  will  be  taken  up  under  separate 
heads.  There  is,  however,  a  general  principle  involved  which 
should  be  followed  in  all  cases,  the  foundation  of  which  is  that 
the  digestive  functions  are  either  arrested  or  greatly  impaired 
after  operations,  the  outcome  of  the  narcosis  as  already  rather 
extensively  discussed,  and  because  of  shock  and  the  disarrange- 
ment of  the  vital  functions  to  be  expected  as  the  result  of  a  severe 
tax  upon  them.  As  stated,  no  food  should  be  given  by  mouth 
while  the  patient  is  vomiting,  and  nothing  should  be  given  until 
nausea  has  disappeared.  The  administration  of  agents  to  "  settle 
the  stomach  "  should  be  avoided. 

FEEDING   BY   MOUTH 

As  soon  as  nausea  has  disappeared,  kumyss  or  matzoon  may  be 
given  in  small  quantities  at  a  time  (half  an  ounce).  The  second 
dose  of  these  agents  should  not  be  administered  until  a  reasonable 
period  of  time  has  elapsed  to  determine  whether  the  stomach  will 
reject  it  or  not.  This  should  be  about  half  an  hour.  The  quan- 
tity of  the  second  dose  should  be  about  the  same  as  the  first,  and 
this  may  be  repeated  if  no  nausea  appears  in  fifteen  minutes.  At 
the  end  of  three  or  four  hours  additional  liquid  food  may  be  al- 
lowed. It  is  not  sufficient  to  give  general  instructions  in  this 
regard — the  orders  should  be  definitely  expressed,  and  execution 
insisted  upon. 

If  no  untoward  conditions  arise  it  may  be  regarded  as  safe 
to  give  almost  any  liquid  nourishment  which  the  patient  desires 

288 


FEEDING  BY  MOUTH  289 

at  the  end  of  twenty-four  hours.  Broths,  beef  extracts,  and  the 
nostrums  on  the  market  exploited  as  being  readily  assimilated, 
organic,  nitrogenized  constituents  of  diet,  are  not  objectionable  as 
far  as  their  palatability  is  concerned.  It  is  to  be  borne  in  mind, 
however,  that  none  of  these  may  properly  be  regarded  as  of  great 
nutritive  value.  Soups  and  broths  consist  of  a  solution  of  in- 
organics extracted  from  meat  by  various  processes,  all  of  which 
involve  the  application  of  heat.  Heat,  of  course,  coagulates  al- 
bumin, and  the  longer  heat  is  applied  the  firmer  is  the  coagulum 
and  the  less  liable  are  the  albuminoids  to  be  found  in  the  extracts. 
It  is  no  great  exaggeration  to  say  that  soups,  broths,  and  the 
various  so-called  peptones  prepared  by  the  manufacturer  have  the 
chemical  composition  of  urine. 

They  do,  however,  have  some  virtue  as  far  as  the  water  is 
concerned,  and  as  they  hold  certain  flavoring  substances  in  solu- 
tion or  in  mechanical  mixture,  they  fill  a  certain  place  in  relieving 
the  monotony  of  liquid  food.  Milk  and  its  preparations,  i.e.,  its 
modifications,  should  be  the  sheet  anchor  in  liquid  nourishment 
in  postoj^erative  cases,  as  it  is  in  all  conditions  calling  for  the 
administration  of  liquid  diet.  Milk  contains  all  the  ingredients 
necessary  to  maintain  life.  It  is  deficient  in  iron,  but  this  need 
not  be  regarded  as  an  objectionable  omission  when  used  over  a 
short  period  of  time. 

The  modification  of  milk  in  order  to  render  it  more  easily 
assimilable  relates  to  the  fats  and  the  treatment  of  the  casein  to 
prevent  its  firm  coagulation.  As  the  fats  are  most  largely  di- 
gested in  the  intestine  and  require  for  assimilation  considerable 
effort  on  the  part  of  the  digestive  functions,  these  should  be  quite 
removed  and  so-called  skimmed  milk  given  for  the  first  twenty- 
four  hours  after  an  operation.  In  this  way  most  of  the  fat  is 
removed,  though  a  little  is  partaken  of.  However,  this  small  quan- 
tity does  not  call  for  great  labor  on  part  of  the  pancreas,  bile, 
and  intestinal  juices,  and  need  not  be  regarded  as  objectionable. 

"With  respect  to  rendering  more  readily  assimilable  the  casein, 
this  may  be  achieved  by  the  addition  of  lime  water  or  fermenta- 
tion with  lactic  acid.  Knmvss  and  matzoon  are  examples  of  this 
process,  though  the  carbonic  acid  gas  developed  as  the  outcome  of 
this  treatment  may  be  objectionable  in  some  instances.  If  this 
be  true,  then  skimmed  milk  which  has  had  lime  water  added  may 


290  FEEDING   AFTER   OPERATION 

be  used  for  a  day  or  two  after  the  operation,  and  gradually,  as 
the  indications  are  presented,  the  quantity  of  fats  may  be  in- 
creased. The  principle  to  be  kept  in  view  is  to  lessen  the  burden 
of  digestion  and  yet  not  withdraw  nourishment. 

All  operative  cases  have  fever  from  some  cause,  the  most  com- 
mon, of  course,  being  the  outcome  of  exaggerated  metabolism  in 
the  effort  the  economy  makes  in  repair.  This  rise  of  temperature 
does  not,  as  a  rule,  persist  after  the  third  or  fourth  day  unless  it 
be  the  expression  of  infection.  Until,  then,  the  temperature  ap- 
proaches the  normal,  liquid  food  only  should  be  allowed,  on  the 
grounds  stated. 

Peculiar  methods  of  treating  postoperative  cases  by  starvation 
and  the  administration  of  only  water  or  substances  which  are 
soluble  in  water  are  to  be  deprecated.  There  is  no  other  source 
of  energy,  as  has  been  stated  before,  than  the  food  taken  into  the 
body,  and  while  excessive  strain  upon  the  organs  concerned  in  pre- 
paring nutritive  constituents  into  assimilable  substances  is  to  be 
avoided,  the  entire  withdrawal  of  the  organic  nitrogenized  con- 
stituents and  the  fats  is  also  unwise.  Sugar  is  certainly  soluble 
in  water,  yet  its  conversion  into  glucose  is  an  exceedingly  com- 
plicated process  and  unquestionably  entails  greater  effort  in  diges- 
tion than  do  the  albuminoids,  which,  as  is  well  known,  are  di- 
gested very  largely  in  the  stomach. 

•  If  physiology  is  to  be  believed,  the  body  will  be  better  able  to 
furnish  the  constituents  necessary  to  combat  the  outcome  of  sur- 
gical attack  if  it  be  furnished  by  the  ingesta  with  the  material 
to  do  it. 

If  no  infection  be  manifest  by  the  fourth  day,  it  is  proper  to 
furnish  the  patient's  digestive  organs  with  the  fibrin  so  necessary 
to  life,  and  this  is  best  given  in  the  form  of  lean  meats,  which 
at  first  are  given  only  once  daily  and  later  twice  daily.  Repair  of 
injury  will  be  enhanced  by  observation  of  certain  well-established 
physiological  laws,  one  of  which  is  that  man  is  essentially  an 
omnivorous  animal,  as  shown  by  the  anatomy  of  the  digestive  tract. 
Finally,  it  is  well  to  remember  that  the  dissociation  of  the  various 
constituents  of  so-called  vegetable  diet  requires  considerable  effort 
on  the  part  of  the  digestive  organs. 

Especially  is  nourishment  to  be  maintained  if  the  operation 
be  undertaken  for  the  relief  of  an   affliction  which  has  already 


RECTAL  FEEDING  291 

severely  taxed  the  patient's  resistance.  In  this  instance  it  is  best 
to  err  on  the  side  of  excessive  nourishment,  provided  the  digestive 
organs  give  no  evidence  of  inability  to  perform  their  functions. 
The  adjustment  of  this  question  will  call  for  the  exercise  of  con- 
siderable judgment  on  the  part  of  the  attendant,  who  is  admonished 
to  study  carefully  the  case  and  be  guided  by  the  general  rules  here 
laid  down.  Alcohol,  morphin,  and  the  like  are,  of  course,  to  be 
avoided.  Yet,  as  stated  under  the  head  of  preparation  of  the 
patient,  the  time  to  effect  cure  with  regard  to  habits  of  this  sort 
is  not  either  immediately  before  or  after  an  operation. 

Alcohol  itself  presents  a  slightly  more  complex  problem.  It 
is,  no  doubt,  fair  to  say  that  it  should  be  avoided  if  feasible,  bear- 
ing in  mind  that  it  has  a  certain  place  in  the  science  of  medicine 
aside  from  the  question  of  the  propriety  of  its  use  from  a  social, 
moral,  or  economic  view.  If  the  patient  requires  alcohol  it  should 
be  given  under  the  directorate  of  the  attendant,  in  response  to  cer- 
tain well-known  manifestations,  and  its  administration  carefully 
controlled. 

To  totalize  the  proposition,  give  nothing  by  mouth  until  nausea 
ceases,  use  skimmed  milk,  kumyss,  and  matzoon  for  the  first  twenty- 
four  hours,  and  liquid  food  when  there  is  fever.  As  soon  as  the 
postoperative  fever  is  over  give  ordinary  articles  of  diet  as  the 
digestive  organs  show  evidence  of  being  able  to  handle  them. 

RECTAL   FEEDING 

If  vomiting  and  nausea  persist  beyond  twenty-four  hours  after 
the  operation,  rectal  feeding  must  be  resorted  to.  Life  may  be 
maintained  for  weeks  by  rectal  alimentation.  It  should  not  be 
reserved  as  a  desperate  measure  in  postoperative  cases.  As  stated, 
if  the  indications  justify  it,  it  should  be  begun  at  the  end  of 
twenty-four  hours.  For  this  purpose,  six  ounces  of  milk  which 
has  been  peptonized  by  the  cold  process  should  be  permitted  to 
enter  the  rectum  from  a  fountain  syringe  through  a  small  rectal 
tube,  every  four  to  six  hours. 

The  rectum,  if  necessary,  should  be  cleansed  by  an  enema  be- 
fore the  first  nutritive  enema  is  given.  Each  nutritive  enema 
need  not  be  preceded  by  cleansing  of  the  rectum.  The  frequent 
manipulations  in  this  situation  cause  irritation,  and  if  nutrition 
21 


292  FEEDING  AFTER   OPERATION 

need  be  carried  on  in  this  way  for  more  than  a  day,  one  cleansing 
enema  in  twenty-four  hours  is  sufficient,  though  in  some  cases  this, 
as  the  outcome  of  natural  catharsis,  may  be  unnecessary.  A  nutri- 
tive enema  need  not  be  given  oftener  than  every  four  hours,  and 
one  every  six  hours  is  preferable.  Alcohol  or  medicinal  agents 
may  be  incorporated  in  the  enema,  bearing  in  mind,  of  course, 
that  the  dosage  required  is  larger  when  administered  in  this  way. 

An  attempt  has  been  made  to  give  in  this  way  a  pint  or  more 
of  nutritive  substance  at  one  dose,  injecting  it  high  into  the  sig- 
moid. This  has  not  been  found  serviceable,  however,  the  agent 
being  expelled  soon  after  introduction,  due  to  the  fact  that  ab- 
sorption of  nutritive  substances  from  the  sigmoid  and  rectum  is 
slow,  and  large  quantities  of  these  cause  irritation.  This  does 
not  apply  to  the  introduction  of  saline  solutions,  no  doubt  owing 
to  the  fact  that  water  readily  enters  the  circulation  in  this  way. 

If  the  necessity  for  maintaining  nourishment  for  more  than 
two  or  three  days  arises,  as  is  at  times  the  case  following  opera- 
tions upon  the  stomach  or  upper  portion  of  the  intestines,  feeding 
by  the  rectum  may  be  varied  from  the  method  mentioned  above. 
Milk  proteids  are,  according  to  Luele,  Tluber,  and  Ewald,  not 
readily  absorbed  unless  peptonized,  and  eggs  alone  are  very  slowly 
absorbed  unless  twenty  grains  of  sodium  chlorid  are  added  to  each 
egg.  Raw  beef  juice  is  rapidly  absorbed,  as  might  be  expected, 
since  it  contains  but  little  albumin  and,  indeed,  not  sufficient  in 
quantity  to  constitute  a  helpful  nutritive  constituent.  Peptones 
are  well  absorbed. 

Glucose  is  rapidly  taken  up  if  it  is  not  in  concentrated  solu- 
tion, in  which  event  it  is  likely  to  irritate  the  mucosa  of  the  rectum 
or  colon  and  be  expelled.  It  should  not  be  used  in  solution  stronger 
than  15  per  cent.,  nor  in  larger  quantity  than  300  c.c.  at  a  single 
injection,  the  injections  being  given  six  hours  apart.  Starch 
even  in  the  raw  state  is  well  absorbed,  and  is  not  irritating. 

Fats  are  very  slowly  absorbed,  which  is,  of  course,  to  be  ex- 
pected, as  the  emulsification  of  these  substances  is  carried  on  in 
this  situation  by  the  intestinal  secretions,  which  have,  of  necessity, 
undergone  considerable  change  of  composition  when  they  reach 
the  large  gut,  and  more  especially  the  rectum.  Not  more  than  ten 
grammes  of  fat  are  absorbed  in  a  day,  and  then  only  when  sodium 
chlorid  has  been  added  to  the  mixture.     The  fats  of  milk  are 


RECTAL  FEEDING  293 

slightly  more  readily  taken  up  than  other  kinds.  Alocohol,  in  the 
form  of  whisky,  wine,  or  brandy,  well  diluted,  is  taken  up  very 
readily.  Brandy,  being  a  grape-end  product,  is  perhaps  more 
serviceable  in  this  connection  than  the  grain  alcohols  (whisky). 

Adding  up  the  situation,  it  would  seem  that  the  substances  men- 
tioned are  absorbed  with  expediency  in  the  following  order:  al- 
cohol, albuminose  or  peptones,  eggs  with  salt,  beef  juice,  unboiled 
starch,  diluted  solutions  of  grape  sugar.  Milk,  while  not  freely 
taken  up  in  its  raw  state,  when  peptonized  makes  the  best  vehicle 
for  all  nutritive  enema ta. 

Red  wine  has  been  advocated  by  many  observers  and  its  value 
ascribed  to  its  slight  astringency,  which  quality  renders  it  better 
borne  by  the  rectum.  Fresh  blood  has  been  advocated  by  Ricketts 
of  Cincinnati,  who  uses  from  five  to  ten  ounces  of  defibrinated 
blood  daily.  The  blood  must  be  fresh.  The  extraction  of  the 
fibrin  means,  of  course,  a  chemical  change  in  this  fluid,  which 
robs  it  of  some  of  its  nutritive  value.  However,  Ricketts  reports 
having  kept  a  patient  alive  for  six  weeks  by  its  use,  ultimately 
achieving  a  favorable  result.  The  administration  of  enemata  for 
the  purpose  of  feeding  the  patient  should  not  be  confused  with 
those  given  with  the  view  of  obviating  shock,  which  latter  have 
already  been  discussed  (page  264). 

Tuttle  uses  the  following  formula: 

3  eggs. 

l/o  teaspoonful  of  salt. 

G  ounces  of  peptonized  milk. 

1  tablespoonfnl  of  rye  whisky. 

The  writer  substitutes  brandy  for  the  whisky  for  the  reason 
stated  above. 

Ewald  uses : 

2  eggs. 

1  glass  of  red  wine. 

1  cup  of  20  per  cent,  solution  of  grape  sugar. 

This  enema  may  be  used  when  the  peptonized  milk  is  not 
satisfactorily  retained. 

Boas  finds  the  following  mixture  suitable  in  most  cases,  espe- 


294  FEEDING   AFTER    OPERATION 

eially  as  a  routine  enenia  following  operations  attended  with  pro- 
longed vomiting: 

Milk ....:.  .250  c.c. 

Yolk  of  egg 2 

Salt 1  pincli 

Red  wine 15  c.e. 

As  to  how  long  rectal  alimentation  may  be  continued  is  not 
definitely  settled.  Hutchinson  states  that  it  is  impossible  to  develop 
more  than  500  calories  of  energy  daily  by  this  means,  whereas  at 
least  1,500  are  required  by  patients  to  maintain  the  equilibrium 
of  health.  The  experiments  of  Tournier,  Gross,  Eivald,  and 
others  do  not  bear  him  out  in  this  claim.  A  patient  has  been  kept 
alive  by  this  method  for  twenty-six  days,  so  that  an  extensive 
gastric  nicer  has  been  cured  because  of  the  functional  rest  to  the 
stomach ;  she  lost  flesh,  but  was  no  more  emaciated  than  one  often 
finds  after  attacks  of  typhoid  fever  or  other  exhausting  acute  in- 
fectious disease  (Tuttle).  It  is  to  be  remembered,  however,  that 
Hutchinson  speaks  of  "  maintaining  a  balance  of  health,"  which 
is  an  entirely  different  proposition  from  keeping  a  patient  alive 


Fig.  215. — Wales'  Soft-rubber  Rectal  Bougie.     (Tuttle.) 

who  is  living  also  on  the  adipose  tissue  and  to  some  extent  upon 
the  organic  nitrogenized  constituents  of  the  body.  These  are  not 
so  readily  exhausted  when  supplemented  by  a  certain  nutritive 
constituent  introduced  into  the  rectum  and  taken  up  by  the  circu- 
lating fluid.  As  a  rule,  it  may  be  said  that  patients  who  possess 
ordinary  resistance,  and  whose  calories  have  not  already  been  in- 
ordinately taxed  or  exhausted  by  prolonged  illness  previous  to  the 
operation,  may  be  maintained  alive  and  with  no  alarming  reduc- 
tion of  weight  for  twenty  days  as  the  result  of  judicious  rectal 
feeding.  This  assumption  is  quite  borne  out  by  clinical  experience. 
The  method  of  administering  these  enemata  is  as  follows :  The 
patient  is  placed  in  the  Sims's  position  with  the  hips  elevated. 
A  Xo.  5  ~\Yales  soft  bougie  (Fig.  215),  well  lubricated,  is  gently 
introduced  through  the  anus  and  into  the  rectum,  and  whatever 
gas  may  be  present  is  allowed  to  escape.     The  bougie  is  intro- 


RECTAL  FEEDING  295 

duced  a  distance  of  S1/^  inches.  As  already  stated,  the  sigmoid 
rebels  more  actively  against  the  introduction  of  substances  of  this 
sort  than  does  the  rectum,  and  for  the  purpose  of  nourishment, 
enemas  should  not  be  allowed  to  enter  the  sigmoid  directly.  A 
certain  amount  of  the  fluid  trickles  slowly  into  the  sigmoid  in  this 
way  and  is  not  expelled. 

The  fluid  should  be  injected  very  slowly,  using  a  fountain 
syringe  for  the  purpose  rather  than  the  ordinary  rectal  syringe. 
The  fountain  syringe  should  not  be  raised  more  than  two  feet  above 
the  anal  level.  The  small,  soft  rubber  Wales  tube  is  used  in  order 
to  avoid  injury  to  the  anal  mucosa  when  introduced,  thus  avoiding 
irritation  in  this  location,  which  interferes  with  subsequent  manip- 
ulations. The  fluid  should  be  heated  to  100°  F.  Cold  or  hot 
solutions  are  not  well  borne  by  the  rectal  mucosa,  and  the  enema 
is  likely  to  be  immediately  exj^elled  if  its  temperature  is  not 
watched. 

The  formulae  mentioned  above  will  meet  the  indications  in 
almost  any  case.  The  conception  held  by  the  writer  with  respect 
to  the  food  value  of  certain  so-called  beef  extracts  is  not  shared  by 
all  observers.  For  this  reason,  a  number  of  formula?  are  added 
with  the  view  of  meeting  the  inclination  of  readers  who  take  an 
opposite  view.  The  formulae  are  taken  verbatim  from  Tattle  s 
work  on  the  "  Rectum  and  Pelvic  Colon." 

BiegYs  formula: 

Milk 250  c.c; 

Eggs  2  to  3 ; 

Salt  2  to  3  pinches; 

Eed  wine 30  grammes. 

Catillous  formula: 

Beef  peptone  (saturated  solution) .       5.0  grammes; 

Water    125  grammes; 

Bicarbonate  of  soda 30  centigr. ; 

Laudanum   4  drops. 

Tournier : 

Salted  bouillon 140  to  150  grammes; 

Yolk  of  egg 2  ; 

Wine    20  to  40  grammes ; 

Sydenham's  laudanum   ....        4  to  8  drops. 


296  FEEDING  AFTER   OPERATION 

Tournier : 

Milk    140  grammes ; 

Yolk  of  egg 2 ; 

Sugar    10  grammes ; 

Laudanum    4  to  8  drops. 

Tournier : 

Bouillon   140  grammes ; 

Yolk  of  egg 6 ; 

Wine    20  grammes ; 

Salt    2  teaspoonfuls. 

Tournier  : 

Water    •  •  •  150  grammes ; 

Dry   peptone    10  grammes ; 

Yolk  of  egg 1 ; 

Glucose 20  grammes ; 

Sydenham's  laudanum    4  drops. 

Professor  Jaccoud's  formula : 

Bouillon    250  grammes ; 

"Wine 150  grammes ; 


Yolk  of  egg 2 


Dry  peptone 4  to      20  grammes. 

Lathier  employs : 

Dry   peptone    3  teaspoonfuls: 

Yolk  of  egg 1 ', 

Milk    • 125  grammes ; 

Tincture  of  opium 5  drops ; 

Starch-powder   5  grammes. 

Adamkicivicz  recommends : 

Dry  peptone   100  grammes , 

Flour   300  grammes ; 

OH 90  grammes ; 

Salt    30  grammes ; 

Bouillon    1,000  grammes. 

In  several  injections. 


RECTAL  FEEDING  297 

Fleiner  : 

Bouillon   200  grammes ; 

White  wine 50  grammes. 

Singer  uses : 

Milk    125  grammes ; 

Wine 125  grammes; 

Yolk  of  egg 1 ; 

Salt    2  grammes ; 

Witt's  dry  peptone   1  teaspoonf ul ; 

Glucose    2  grammes. 

Schlesinger  employs : 

Milk    200  grammes ; 


Eggs 


9 


Wine 15  grammes ; 

Eice  flour 6  grammes ; 

Salt   2  pinches. 

Ratjen  uses: 

Milk    250  grammes ; 

Yolk  of  egg 2 ; 

Salt    1  pinch ; 

Bed  wine   ., 15  grammes; 

Starch   15  grammes. 

It  will  be  noticed  that  some  writers  add  a  small  amount  of 
opium  to  the  mixture.  This  has  some  advantages  in  cases  when 
prolonged  rectal  feeding  is  necessary.  The  small  amount  of 
opium  contained  in  each  enema  does  not  have  a  noticeable  con- 
stitutional effect  upon  the  patient,  being  intended  only  to  soothe 
the  irritated  mucosa.  On  the  other  hand,  the  presence  in  the 
fluid  of  an  opiate  lessens  the  rapidity  with  which  the  nutritive 
constituents  are  absorbed.  The  mucosa  does  not  functionate  as  well 
when  the  opium  is  used  as  it  does  without  it.  A  certain  amount 
of  discretion  will  have  to  be  exercised  in  this  connection.  At 
times  copious  lavage  of  the  lower  gut  through  a  Kemp  return 
tube  will  cleanse  very  thoroughly  the  mucosa,  which,  when  rested 
for  six  hours,  will  again  take  up  its  function  and  permit  of  the 
resumption  of  this  avenue  of  nutrition. 


CHAPTEE   XV 
CARE   OF   WOUNDS   AFTER   OPERATIONS 

Time  of  changing  dressings — Preparation  for  change  of  dressings — Exposing 
the  wound — Removal  of  stitches — Cleansing  and  drainage  of  infected 
wounds. 

The  primary  dressing  of  operative  wounds  has  already  been 
described  and  its  rationale  discussed.  With  the  application  of 
the  retention  bandage,  the  office  of  the  surgeon  ceases  in  a  large 
number  of  instances,  and  the  subsequent  care  of  the  wound 
evolves  upon  the  practitioner.  This  has  led  to  more  annoying 
complications  as  regards  the  relationship  the  practitioner  bears 
to  the  patient  than,  perhaps,  any  other  phase  of  the  treatment  of 
operative  cases.  For  instance,  the  occurrence  of  stitch  abscess 
ten  or  twelve  days  after  the  operation  is  frequently  regarded  as 
the  outcome  of  a  factor  for  which  the  practitioner  is  held  respon- 
sible. That  this  is  a  faulty  conclusion  has  already  been  shown. 
However,  it  is  probable  that  infection  of  the  wound  may  take 
place  subsequent  to  the  operation,  as  the  result  of  faulty  technie. 

It  is  also  true  that  at  the  end  of  several  days  after  the  opera- 
tion the  process  of  repair  has  advanced  sufficiently  far  to  make 
infection  exceedingly  unlikely,  and  that  ordinary  precautions 
will  avoid  this  contingency.  The  more  remote  the  first  disturb- 
ance of  the  surroundings  of  the  wound  is  from  the  time  of  opera- 
tion the  less  liable  is  infection  to  occur,  and  this  argues  for  the 
avoidance  of  early  interference  with  wounds  as  long  as  there  is 
no  direct  indication  to  the  contrary.  This  assumption  is  borne 
out  by  experience,  and  if  the  general  trend  be  that  of  conservatism 
and  patience  rather  than  meddlesome  enthusiasm,  the  interests  of 
all  are  best  conserved. 

The  surgeon  is  warned  that  a  heated  denunciation  of  the  prac- 
titioner's lack  of  skill  in  the  after-care  of  the  wound  is  objec- 
tionable, and  more  so  as  the  infection  may  easily  have  been  the 

298 


TIME   OF   CHANGE   OF   DRESSINGS  299 

result  of  some  occurrence  at  the  time  of  the  operation,  and  the 
practitioner  be  in  no  wise  responsible  for  it.  Frequently,  the  re- 
sult of  unavoidable  infection  of  the  woujjid  is  that  the  practitioner 
and  the  surgeon  devote  considerable  time  and  effort  in  useless 
attempts  to  fix  the  responsibility  of  a  late  skin  infection  upon  each 
other,  when,  as  a  matter  of  fact,  neither  may  be  responsible. 
Certain  it  is  that  this  possibility  should  cause  both  to  avoid  dis- 
play of  annoyance  for  the  benefit  of  the  family  and  friends. 

The  after-care  of  operative  wounds  varies  with  whether 
drainage  has  been  employed.  Clean  wounds  in  which  no  drain- 
age has  been  used  will  heal  without  change  of  dressing,  and  the 
latter  need  not  be  removed  until  the  tenth  day  in  order  to  remove 
the  sutures.  If  the  suture  material  used  in  the  skin  is  catgut, 
the  dressing  need  not  be  removed  for  this  purpose,  but  should  be 
changed  in  order  to  permit  of  cleansing  of  the  parts  contiguous 
to  the  wound  which  have  been  covered  by  the  protective  dressing 
and  where  secretions  have  accumulated.  Indeed,  in  cases  where 
an  elaborate  protective  dressing  has  been  applied,  the  outer 
dressings  may  be  changed  on  the  fourth  or  fifth  day,  but  the 
portion  of  dressing,  immediately  contiguous  to  the  wound  need 
not  be  and,  indeed,  is  best  not  disturbed  at  this  time. 

Frequently  the  patient  will  complain  of  itching  and  irrita- 
tion in  the  skin  beneath  the  dressings,  and  if  the  bandage  or 
binder  be  released,  the  skin  sponged  with  alcohol  and  warm 
water,  and  a  clean  outer  dressing  applied,  the  comfort  given  the 
patient  will  be  found  exceedingly  desirable.  As  has  already  been 
stated,  non-absorable  suture  material  is  less  likely  to  be  compli- 
cated with  stitch  abscesses  than  the  absorbable  variety,  and  re- 
quires removal  at  the  end  of  ten  days.  It  is  to  be  remembered 
that  the  removal  of  stitches  disturbs  the  repair  process  which  has 
taken  place  in  the  line  of  the  buried  portion  of  the  suture,  and 
this  trauma,  slight  as  it  is,  makes  again  a  field  which  is  suscep- 
tible of  infection,  though,  of  course,  this  is  not  as  likely  to  oc- 
cur as  obtains  during  the  operation  itself. 

TIME   OF   CHANGE   OF   DRESSINGS 

The  indications  for  removal  of  the  dressings  in  wounds 
which  have  not  been  drained  are  expressed  in  the  temperature 


300  CARE  OF   WOUNDS  AFTER  OPERATIONS 

and  pulse  rate.  Indeed,  in  the  usual  symptoms  of  inflamma- 
tion. This  does  not  mean  that  rise  of  temperature  or  increase  of 
pulse  rate  at  the  end  of  forty-eight  hours  after  an  operation  calls 
for  change  of  dressings.  Indeed,  this  may  he  due  to  a  number 
of  causes,  but  if  the  temperature  and  increased  pulse  rate  persist 
into  the  third  or  the  fourth  day,  and  are  not  accounted  for  by  other 
causes,  the  dressings  should  be  removed  and  search  made  with  the 
view  of  disclosing  local  conditions  which  account  for  the  dis- 
turbed metabolism. 

In  these  instances  infection  of  the  wound  will,  no  doubt,  be 
manifest,  and  the  release  of  one  or  more  of  the  sutures  will  give 
opportunity  for  the  discharge  of  the  inflammatory  exudate,  and 
in  the  vast  majority  of  instances  this  measure  will  afford  relief 
of  the  symptoms,  and  the  only  setback  to  meet  will  be  the  fact 
that  healing  by  granulation  will  take  place  instead  of  primary 
union. 

When  the  wound  is  dressed  for  the  purpose  of  removing 
stitches  which  are  no  longer  of  service,  or  with  the  view  of  dis- 
covering and  treating  infection,  the  technic  of  the  procedure  is 
the  same.  All  the  material  which  comes  in  contact  with  the 
wound  and  its  immediate  surroundings  should  be  sterile.  This 
is,  of  course,  more  imperative  when  the  protective  dressing  is 
disturbed  soon  after  the  operation  than  if  the  ten  days  spoken  of 
above  have  been  allowed  to  elapse.  However,  the  precautions 
should  be  just  as  rigidly  enforced  in  the  latter  instance. 

As  the  change  of  dressing  usually  takes  place  when  the  pa- 
tient is  in  bed,  either  in  the  hospital  ward  or  room,  provision 
should  be  made  for  transportation  of  sterile  material.  In  hos- 
pital practice  this  is  quite  a  matter  of  routine  and,  indeed,  in 
private  practice  the  preparation  of  dressings,  as  already  de- 
scribed, renders  the  problem  quite  simple.  Whatever  the  selec- 
tion of  the  surgeon  may  be  as  to  asepsis  or  antisepsis  with  regard 
to  operating-room  technic,  there  can  be  no  doubt  that  the  latter 
is  the  more  advisable  when  the  dressing  is  changed. 

PREPARATION   FOR   CHANGE    OF   DRESSING 

The  prolonged  preparation  of  the  hands  necessary  to  cleanse 
the  skin  would  entail  considerable  hardship  upon  the  attendant. 


PREPARATION   FOR  CHANGE   OF   DRESSING  301 

Indeed,  if  it  were  necessary  to  go  through  the  same  elaborate 
mechanical  and  chemical  cleansing  of  the  hands  necessary  to 
achieve  the  purpose  each  time  a  case  were  dressed,  the  attendant 
would  not  have  much  skin  left.  When  dressing  cases,  the  rubber 
gloves  fill  an  exceedingly  useful  purpose,  and  a  pair  of  sterile 
gloves  should  be  prepared  for  the  attendant  for  each  case.  As 
there  is  no  violent  manipulation  attendant  upon  changing  the 
dressing,  gloves  are  not  frequently  perforated  during  the  dress- 
ing, and  the  question  of  economy  is  not  so  important  a  factor. 
A  convenient  method  of  handling  gloves  is  to  have  each  pair 
wrapped  in  a  towel  together  with  a  small  quantity  of  talcum 
powder  in  a  small  envelope,  which  are  readily  sterilized  in  the 
steam  sterilizer.  The  gloves  can  be  readily  transported  in  this 
way,  and  when  about  to  be  used,  the  nurse  opens  the  package 
and  the  attendant  dusts  his  hands  with  the  powder  and  slips  into 
the  left  glove,  being  careful  not  to  touch  any  portion  of  the  glove 
except  the  gauntlet,  which  is,  of  course,  not  allowed  to  come  in 
contact  with  the  wound  or  its  surroundings.  The  right  glove 
may  now  be  lifted  with  the  fingers  of  the  left  gloved  hand, 
and  as  these  are  sterile,  the  manipulation  need  not  be  limited 
to  the  gauntlet.  If  the  glove  on  the  left  hand  is  not  properly 
adjusted  by  the  first  act,  it  may  be  manipulated  into  place  by 
the  right,  as  now  only  sterile  surfaces  come  in  contact  with  each 
other. 

The  attendant  does  not  remove  the  outer  dressings,  but  has 
the  nurse  cut  the  bandages  or  loosen  the  binder,  as  the  case  may 
be,  and  remove  the  combination  dressing. 

For  purposes  of  illustration,  a  description  of  the  technic  of 
dressing  a  wound  is  given  in  connection  with  a  wound  of  the 
thigh,  but  is  to  be  regarded  as  applicable  to  all  portions  of  the 
body. 

For  the  purpose  the  nurse  should  prepare : 

Six  sterile  towels. 

Basin  with  wipes  in  carbolic  acid  1  in  100. 

Pus  basin. 

Kelly  pad. 

Bandage  scissors. 

Tray  with  sterile  scissors  for  cutting  dressings. 


302  CARE   OF   WOUNDS   AFTER   OPERATIONS 

Thumb  forceps,  plain. 

Scissors  for  cutting  stitches. 

Dressing  forceps. 

Director. 

Glass  nozzle  for  irrigator  tube. 

Package  of  four-by-four  sponges. 

Package  of  two-by-two  sponges. 

Irrigator  containing  solution  of  biehlorid  1  in  1,000. 

Hydrogen  peroxid. 

Same  dressings  as  used  at  operation. 

EXPOSING  THE   WOUND 

The  thigh  is  exposed  together  with  its  encasing  dressing,  and 
the  outer  bandage  and  the  dressings  down  to  the  last  piece  of 
gauze,  which  is  usually  found  adherent  to  the  wound,  are  re- 
moved. The  parts  immediately  contiguous  to  the  wound  are  pro- 
tected with  sterile  towels  (Fig.  216),  in  order  to  obviate  con- 
tamination of  any  of  the  instruments,  sponges,  etc.,  which  may 
come  in  contact  with  these  parts.  It  is  wise  to  slip  a  Kelly  pad 
under  the  dependent  portion  of  the  part  in  order  to  catch  fluids 
which  are  used  in  the  dressing.  However,  unless  irrigation  or 
copious  lavage  is  necessary,  a  simple  pad  of  absorbent  cotton  or  a 
few  towels  folded  upon  themselves  and  placed  at  the  dependant 
part  will  suffice  for  the  purpose. 

A  gauze  or  cotton  "  tupfer  "  is  now  removed  from  the  basin 
containing  the  carbolic  solution  (1  in  100),  and  the  fluid  allowed 
to  drip  over  the  portion  of  gauze  corresponding  to  the  area  of 
the  wound.  The  latter  is  usually  clearly  indicated  by  the  stain 
from  the  secretions  of  the  wound  (Fig.  216).  This  moistens  the 
gauze  and  permits  of  its  more  easy  removal.  However,  in  some 
instances  the  dry  crust  consisting  of  blood  and  antiseptic  powder 
is  rather  tenacious,  and  the  measure  indicated  is  not  effective. 
In  these  instances  force  should  not  be  used,  but  a  glass  syringe  is 
filled  with  hydrogen  peroxid  and  the  latter  injected  under  the 
edge  of  the  adherent  gauze.  The  effervescence  which  occurs  as 
the  outcome  of  the  contact  of  the  secretions  and  the  peroxid  of 
hydrogen  will  usually  gently  lift  the  gauze  from  the  wound  with- 
out giving  any  pain  to  the  patient.     If  necessary  the  injection 


EXPOSING   THE   WOUND  303 

may  be  several  times  repeated  if  the  first  application  Joes  not 
suffice. 

The  habit  of  forcibly  tearing  the  dressings  from  wounds  is  to 
be  deprecated,  not  alone  on  the  ground  that  unnecessary  pain  is 
inflicted,  but  because  the  trauma,  slight  as  it  is,  to  the  edges  of 
the  wound  favors  late  infection  and  delay  in  repair. 

After  the  last  piece  of  gauze  has  been  removed  the  wound 


Fig.  ,216. — Gauze  in  Contact  with  Wound. 

and  surrounding  skin  is  cleansed  with  the  carbolic  acid  or  corro- 
sive sublimate  solution,  using  for  the  purpose  the  gauze  wipes 
or  tabs  of  cotton.  Care  should  be  exercised  in  this  connection 
not  to  wipe  the  wound  with  a  sponge  which  has  been  used  for 
cleansing  of  the  surrounding  skin  or  vice  versa,  i.e.,  after  the 
wound  has  been  wiped  the  sponge  is  thrown  aside  and  a  fresh  one 
used.  This  also  applies  to  sponges  used  on  the  neighboring  skin. 
The  rationale  of  this  precaution  is  obvious.  Too  frequently  will 
the  interne  or  nurse  swab  the  skin  and  then  apply  the  soiled 
sponge  to  the  wound.  This  is  a  fair  way  to  introduce  infection 
into  the  wound. 

If  the  quantity  of  secretion  be  large,  the  cleansing  of  the  parts 
may  be  supplemented  by  irrigation  with  corrosive  sublimate  solu- 
tion. However,  it  is  best  not  to  employ  this  measure  relying  more 
upon  the  former  method. 


304 


CARE   OF  WOUNDS   AFTER   OPERATIONS 


REMOVAL   OF   THE   STITCHES 

This  simple  measure  may  be  performed  in  a  manner  which 
will  stand  in  a  causative  relationship  to  late  superficial  infec- 
tion. If  the  wound  be  clean, 
the  next  step  is  to  remove  the 
stitches  with  the  minimum  of 
annoyance  to  the  patient,  and 
with  the  view  of  preventing  in- 
fection. Commonly  the  stitch  is 
lifted  by  the  end  of  the  suture 
near  the  knot,  scissors  are  slipped  under  the  stitch,  and  after  its 
division  the  thumb  forceps  are  used  to  remove  the  stitch.  This 
method  of  procedure  is  painful  and  somewhat  awe-inspiring  to 


Fig.  217. — Angular  Probe-pointed 
Scissors  for  Ready  Removal  of 
Stitches  from  Wounds. 


Fig.  218. — Removing  Suture  from  Wound  with  Probe-pointed  Angular 

Scissors. 

the  patient,  despite  the  frequent  admonitions  of  bystanders  "  not 
to  look."  The  writer  employs  for  the  purpose  a  probe-pointed 
scissors  (Fig.  217),  the  lower  blade  of  which  is  slipped  under 
the  portion  of  the  suture  distal  from  the  knot  (Fig.  218).  This 
makes  but  little  tension  on  the  suture,  especially  if  the  lower 
blade  of  the  scissors  is  slightly  depressed  into  the  skin,  as  shown 
in  Fig.  218.     The  little  manipulation  is  accomplished  with  one 


CLEANSING  AND   DRAINAGE   OF   INFECTED   WOUNDS      305 

hand  and  the  suture  is  cut.  The  knot  is  now  seized  with  the 
thumb  forceps  and  the  suture  is  withdrawn.  It  must  be  borne 
in  mind  that  the  portion  of  the  suture  lying  on  the  skin  is  likely 
to  be  the  habitat  of  bacteria,  and  this  should  not  be  dragged 
through  the  suture  bed,  but  the  division  of  the  suture  should  take 
place  near  its  point,  of  egress,  as  shown  in  the  illustration.  The 
measure  is,  of  course,  repeated  for  each  stitch.  If  a  continuous 
suture  is  employed,  each  crossing  of  the  suture  material  is  sepa- 
rately divided,  taking  the  same  precaution  to  avoid  dragging  of 
the  superimposed  part  of  the  suture  through  the  suture  holes. 

CLEANSING  AND   DRAINAGE   OF   INFECTED   WOUNDS 

If  the  wound  be  infected,  it  will  show  itself  in  redness  and 
puffiness,  most  marked  at  the  site  of  the  sutures. 


Fig.  219. 


-Director  Introduced  into  Wound  in  Search  of  Infective 
Secretions. 


In  these  instances  it  is  wise  to  leave  in  situ  as  many  sutures 
as  is  feasible,  to  obviate  wide  separation  of  the  lips  of  the  wound, 
especially  as  infection  usually  manifests  itself  upon  the  fourth 
or  fifth  day  after  the  operation,  and  repair  at  this  time  is  not 
sufficiently  advanced  to  permit  of  their  removal.  A  single  su- 
ture is  now  released  in  the  manner  described,  and  a  director  in- 
troduced into  the  wound  (Fig.  219)  with  the  view  of  disclosing 


306  CARE   OF  WOUNDS   AFTER  OPERATIONS 

the  site  of  suppuration  in  order  that  only  such  sutures  be  re- 
moved to  liberate  infective  material  and  yet  maintain  apposition 
of  the  divided  structures.  Usually  the  most  dependent  suture  is 
removed  at  first  to  facilitate  subsequent  drainage.  This  argues 
for  the  employment  of  interrupted  sutures  in  the  skin,  and  that 
they  should  be  of  material  which  will  withstand  rapid  absorp- 
tion and  manipulation.  If  the  infection  be  located  in  this  way, 
the  upper  suture  may  now  be  removed  and  the  wound  irrigated 
with  a  solution  of  corrosive  sublimate  1  in  1,000,  using  a  conical 


Fig.  220. — Method  of  Cleansing  an  Infected  Wound. 

pointed  glass  nozzle  connected  with  an  irrigator.  The  glass 
nozzle  is  introduced  into  the  upper  end  of  the  wound,  and  the 
lower  end  is  gently  held  apart  with  slender  forceps  to  facilitate 
discharge  of  the  fluid  and  to  prevent  undue  distention  pressure 
upon  the  wound,  which  might  separate  it  unnecessarily  (Fig. 
220).  The  injection  of  peroxid  of  hydrogen  into  the  wound  is 
objectionable  at  this  time  for  the  same  reason.  It  may,  how- 
ever, be  effectually  employed  when  repair  in  the  portion  of  the 
wound  between  the  two  exit  holes  has  advanced  farther.  After 
the  infective  secretions  have  been  entirely  removed  and  the  solu- 


CLEANSING   AND   DRAINAGE   OF   INFECTED   WOUNDS      307 


tion  appears  clear  at  the  dependant  side,  the  irrigation  is  discon- 
tinued and  the  residual  solution  gently  expressed.  A  probe 
armed  with  a  small  layer  of  cotton  soaked  with  iodin  may  now 
be  introduced  the  entire  length  of  the  wound  with  the  view  of 
destroying  bacteria.  This  measure  has  been  found  exceedingly 
effectual  at  the  hands  of  the  writer.  The  smarting  sensation  ex- 
perienced by  the  patient  is  a  minor  consideration  and  disap- 
pears in  a  few  moments.  The  attendant  is  warned  that  the 
iodin   will,    when    coming    in    contact    with    gauze,    convert    the 


Fig.  221. — Dressing  Forceps  Introduced  Through  Wound.     Gauze  seized 
preparatory  to  introduction. 


starch  in  the  gauze  into  the  blue  iodid  of  starch  and  may  lead 

to  the  faulty  notion  that  the  wound  is  infected  with  the  pyo- 

cyaneus  bacillus.     Drainage  is  now  established.      This  may  be 

accomplished  in  the  manner  already  described  under  the  head 

of  drainage  or,  as  is  better,  a  dressing  forceps  is  passed  from  end 

to  end  (Fig.  221)  through  the  wound  and  a  piece  of  gauze  pulled 

through    (Fig.    222).      The   diameter  of  the  gauze  depends,   of 

course,  upon  the  size  of  the  wound.     It  should  not  be  sufficiently 

bulky  to  cause  pressure  which  would  interfere  with  capillarity. 

If  the  gauze  be  moistened  before  introduction  with  carbolic  acid 
22 


308 


CARE   OF   WOUNDS   AFTER  OPERATIONS 


solution  its  introduction  will  be  facilitated  and  final  capillarity 
enhanced. 

Infected  wounds  should  be  dressed  every  twenty-four  hours, 
irrespective  of  systematic  indications.  As  strongly  as  non-in- 
terference is  advocated  for  non-infected  wounds  the  proper  cleans- 
ing of  infected  wounds  is  equally  strongly  insisted  upon.  The 
drain  should,  at  the  second  dressing,  be  shortened.  This  is  ac- 
complished by  cutting  off  the  portion  protruding  from  the  upper 
end  of  the  wound  and  withdrawing  the  gauze  through  the  lower 


Fig.  222. — Gauze  Drainage  in  situ. 

opening.  The  object  of  cutting  off  the  protruding  upper  end  is 
to  prevent  the  portion  of  the  drain  which  has  been  in  contact 
with  the  skin  from  being  dragged  through  the  wound. 

The  wound  is  now  cleansed,  as  stated  above,  and  if  the  quan- 
tity of  infective  secretion  be  small,  a  shorter  drain  is  introduced 
into  the  lower  opening,  which  latter  is  replaced  by  a  shorter 
piece  of  drain  at  each  dressing  until  the  discharge  ceases.  This 
rarely  requires  more  than  ten  days.  The  upper  opening  may,  if 
there  be  undue  gaping  be  held  in  apposition  with  sterile  adhesive 
plaster.  The  lower  opening  is  treated  in  the  same  way  after  the 
drain  has  been  permanently  removed. 


CLEANSING   AND   DRAINAGE   OF   INFECTED   WOUNDS      309 

These  measures  are  applicable  in  eases  of  moderate  infection 
of  the  superficial  wound.  In  instances  where  infection  of  the 
deeper  tissues  occurs  with  cellulitis,  the  measures  need  be  some- 
what more  radical.  In  these  cases  all  the  superficial  sutures 
should  be  removed  and  the  site  of  infection  directly  attacked. 

The  patient  will  probably  require  narcosis,  though  in  some 
cases  the  instillation  of  a  one  per  cent,  cocain  solution  will  con- 
trol the  pain  sufficiently  to  permit  of  the  necessary  manipulations. 
Alter  the  wound  and  surrounding  parts  have  been  cleansed  in 
the  manner  just  stated,  the  superficial  sutures  are  removed  and 
the  deeper  layer  searched  in  the  same  manner,  with  the  director, 
as  described  above.  Here,  again,  it  may  not  be  necessary  to  re- 
move all  the  sutures,  and  if  some  may  be  left  in  situ,  repair  will 
be  conserved.     The  upper  and  lower  stitches  may  be  removed  and 


Fig.  223. — Infected  Wound  Packed  with  Gauze  and  Sutures  Placed. 

the  deep  wound  cleansed  with  the  antiseptic  fluid.  A  drain  is 
passed  beneath  the  suture  line,  as  described  above,  the  ends  of 
which  are  permitted  to  protrude  well  beyond  the  limits  of  the 
wound. 

The  superficial  wound  is  now  loosely  packed   with   iodoform 
gauze.     The  packing  should  not  make  pressure,   but   should  be 


310  CARE   OF   WOUNDS   AFTER   OPERATIONS 

allowed  to  comfortably  fill  the  wound  cavity.  As  infection  may 
be  controlled  by  these  measures,  provision  should  at  this  time  be 
made  for  coaptation  of  the  edges  of  the  wound  when  infection 
has  been  arrested.  For  the  purpose,  interrupted  silk-worm  gut 
sutures  are  introduced  and  left  loose,  being  held  at  their  distal 
ends  with  a  serre-fine.  Fig.  223  shows  a  wound  packed  and  the 
sutures  held  by  a  forceps. 

The  protruding  portion  of  gauze  is  intended  to  facilitate  re- 
moval of  the  packing.  At  the  next  dressing  this  is  seized  with 
dressing  forceps,  and  after  the  gauze  packing  has  been  thoroughly 
saturated  with  the  cleansing  solution,  it  is  gently  removed  by 
twisting  it  upon  itself.  Hydrogen  peroxid  may  be  used  for  the 
purpose  as  the  avenue  of  egress  for  the  bubbling  mixture  of 
blood,  and  the  peroxid  is  ample  under  these  conditons. 

When  the  infection  is  controlled,  the  edges  of  the  wound  are 
held  in  apposition  by  tying  the  sutures  in  the  usual  manner, 
leaving,  however,  the  upper  and  lower  corners  of  the  wound 
slightly  open,  with  the  view  of  making  any  necessary  cleansing 
more  readily  accomplished.  This  measure  saves  much  time  in 
ultimate  repair  and  prevents  an  unnecessary  degree  of  scarring. 
Indeed,  it  not  infrequently  happens  that  the  infection  subsides 
at  the  end  of  three  or  four  days  as  the  outcome  of  the  drainage 
and  light  packing,  and  the  early  approximation  of  the  edges  of 
the  wound  makes  possible  an  ultimate  result  not  greatly  at  vari- 
ance with  that  obtained  with  primary  union. 


CHAPTER    XVI 
OPERATIONS   ON   THE  SCALP,   SKULL  AND    BRAIN 

Operations  on  the  scalp:  Preparation  of  the  narcotist — Preparation  of  the 
scalp — Care  of  wounds. 

Operations  on  the  cranium :  Kroenlein  construction — Care  of  wounds  of  cranial 
bones. 

Operations  involving  cranial  contents:  Bone  necrosis — Secondary  hemorrhage 
— Retention  of  cerebrospinal  fluid — Edema  and  softening  of  the  brain 
substance — Discharge  of  cerebrospinal  fluid — Brain  prolapse — The  retain- 
ing bandage — Mastoid  operations — Intracranial  neurectomy. 

OPERATIONS   ON   THE   SCALP 

PREPARATION   OF   NARCOTIST 

Asepsis  during  operations  on  the  head  is  not  readily  obtained 
and  calls  for  especial  precautions.  The  presence  of  the  narcotist 
immediately  contiguous  to  the  operative  field,  the  secretions  from 
mouth  and  nose,  the  occasional  discharge  of  vomitus,  all  contribute 
to  the  factors  which  enhance  the  difficulties  in  this  connection. 

It  is  a  good  rule  to  have  narcosis  produced  by  one  assistant, 
while  a  second  prepares  for  the  narcosis  during  the  operation. 
The  patient  is  narcotized  in  the  ante-room  by  the  first  assistant 
after  the  usual  preliminary  preparation  of  the  operative  field  has 
been  made  and  is  then  transported  to  the  operating  room  and 
placed  on  the  table. 

The  non-sterile  attendant  carefully  removes  the  superficial  re- 
taining bandage  holding  the  protective  dressing  in  place  without 
coming  in  contact  with  the  subjacent  gauze  and  the  narcotizer, 
who  has  prepared  himself  in  the  usual  manner  (Fig.  85)  and 
who  wears  a  sterile  gown,  cap,  mask  and  gloves,  takes  charge  of 
the  narcosis,  using  a  sterile  cone  or  mask  for  the  purpose. 

The  operation  may  then  proceed  with  the  element  of  infec- 
tion, as  far  as  the  narcotist  is  concerned,  eliminated.     The  care 

311 


312         OPERATIONS  ON  THE   SCALP,   SKULL  AND   BRAIN 

of  the  nose  and  mouth  in  operations  in  their  field  is  taken  up 
under  a  separate  head. 

Vomiting  during  the  operation  may  be  controlled  by  judicious 
administration  of  the  narcotic.  This  suggests  that  novices  should 
obtain  their  education  in  this  connection  on  cases  other  than  those 
involving  operations  on  the  head. 

PREPARATION   OF   SCALP 

The  preparation  for  operations  on  the  scalp  cranium,  and  con- 
tents of  the  cranium,  does  not  differ  as  regards  local  steps.  As 
a  rule,  the  entire  scalp  should  be  shaved.  In  cases  requiring  sur- 
gical interference  of  magnitude  this  is  a  minor  consideration. 
However,  in  cases  which  involve  only  the  removal  of  benign 
growths,  such  as  a  sebaceous  cyst,  removal  of  the  entire  hair  is 
perhaps  unwarranted.  Especially  is  this  true  if  the  patient  be 
a  woman. 

In  these  instances  the  following  technic  will  be  found  ser- 
viceable and,  no  doubt,  justifiable.  The  portion  of  scalp  to  be 
attacked,  together  with  a  space  surrounding  it  an  inch  in  breadth, 
is  shaved  and  the'  entire  scalp  thoroughly  anointed  with  olive  oil 
or  white  vaseline.  This  is  done  the  evening  before  the  operation, 
the  object  being  softening  of  the  dried  sebaceous  secretion  with 
which  the  scalp  is  always  more  or  less  covered.  An  hour  before 
the  operation  the  scalp  is  thoroughly  shampooed  with  an  alkaline 
green  soap,  the  alkali  being  intended  to  saponify  the  greasy  mix- 
ture of  the  application  and  the  softened  sebum. 

The  resultant  lather  is  freely  lavaged  with  sterile  water.  Cor- 
rosive sublimate  solution  should  not  be  employed  for  this  pur- 
pose, as  the  alkali  in  the  soap  may  precipitate  the  mercury,  which, 
though  not  particularly  objectionable,  had  best  be  avoided.  The 
corrosive  sublimate  solution  may  be  used  for  its  cleansing  effect 
after  the  soap  has  been  removed  by  lavage  with  sterile  water. 

The  hair  should  now  be  dried  with  a  sterile  towel  and  braided 
(in  women)  in  such  a  way  as  to  direct  it  away  from  the  field 
of  operation.  A  dressing  of  fluffed  sterile  gauze  may  now  be  ap- 
plied to  the  head.  Immediately  before  proceeding  with  the  opera- 
tion the  dressing  is  removed  and  the  denuded  area  painted  with 
tincture  of  iodin.  This  latter  step  takes  place  after  narcosis  is 
established,  or  in  the  event  of  local  anesthesia,  after  the  patient 


OPERATIONS   ON   THE   SCALP 


313 


has  been  conveniently  postured  and  before  apjolication  of  the  local 
anesthetic  is  made. 

In  order  to  isolate  with  certainty  the  operative  field,  a  goodly 
sized  square  of  gauze  composed  of  several  layers  of  this  material 
is  prepared.  About  six  layers  of  gauze  are  used,  between  the 
center  layers  of  which  a  sheet  of  elastic  rubber  is  placed.  An 
opening  a  little  larger  than  the  dimensions  of  the  operative  field, 
but  not  quite  as  large  as  the  denuded  area,  is  cut  into  the  gauze 
protector,  and  this  is  fastened  near  the  margins  of  the  hair  by 
means  of  sutures  of  very  fine  silk  introduced  with  a  slender  needle 
(Fig.  224). 


Fig.  224. — Method  op  Isolating  Portion  of  Scalp  by  Sterile  Gauze 

Protector. 

It  is  quite  impossible  to  place  sterile  towels  in  contact  with 
the  hair,  and  prevent  their  dislodgmcnt  during  the  surgical 
manipulation,  and  the  gauze  fastened  in  the  manner  stated  ef- 
fectually isolates  the  field,  rendering  the  introduction  of  infec- 
tious material  from  the  contiguous  surfaces  quite  unlikely.  The 
elastic  rubber  sheeting  prevents  soiling  of  the  hair  with  blood,  se- 
cretions, and  cleansing  fluids  used  during  the  operation. 


314         OPERATIONS   ON   THE   SCALP,   SKULL   AND   BRAIN 

The  object  may  be  attained  by  fastening  small  towels  around 
the  operation  field  in  the  form  of  a  hollow  square,  the  crossings 
of  which  are  held  fast  to  the  scalp  by  means  of  small  clamps  spe- 
cially constructed  with  sharp  biting  ends.  This,  while  quite  useful, 
is  not  as  effective  a  measure  as  the  one  stated  above.  The  sutures 
holding  the  protector  are  not  removed  until  the  operative  wound 
is  protected  by  the  first  layers  of  the  dressing. 

The  points  of  contact  of  the  edge  of  the  opening  in  the  pro- 
tector may  be  sealed  with  collodion  to  obviate  trickling  of  the 
cleansing  solutions,  etc.,  beneath  the  protector. 

Wounds  of  the  scalp  heal  very  readily  and  do  not  become  in- 
fected with  frequency.  Both  these  characteristics  are  explained 
on  the  ground  that  the  scalp  is  very  vascular  and  that  the  presence 
of  glandular  elements  in  large  number  conserves  the  process  of 
repair.  Fine  silk-worm  gut  or  horsehair  are  the  suture  materials 
of  choice  in  this  class  of  cases. 

CARE   OF  WOUNDS 

Drainage  of  wounds  of  the  scalp  is  not  usually  necessary.  If, 
however,  the  subaponeurotic  space  has  been  invaded  and  the  sur- 
geon be  not  reasonably  certain  of  the  asepsis  during  the  operation, 
a  small  drain  consisting  of  horsehair  or  silk-worm  gut  (page  193, 
Fig.  147)  may  be  introduced  and  left  in  situ  for  several  days. 
If  infection  occurs  and  the  purulent  material  gains  access  to 
the  subaponeurotic  space,  drainage  of  the  wound  itself  will  not 
suffice  in  all  instances.  The  infection  is  exceedingly  likely  to  in- 
vade the  loose  connective  tissue  beneath  the  galea  and  cause  an 
edematous  infiltration  of  the  entire  scalp. 

The  edematous  infiltrate  puffs  up  the  entire  surface  of  the 
cranium  and,  indeed,  invades  the  upper  eyelids.  Patients  afflicted 
in  this  way  suffer  considerable  pain,  and,  indeed,  if  the  periosteum 
be  infected,  present  the  picture  of  an  alarming  condition.  The 
severe  pain  is  due  to  pressure  upon  the  periosteum,  which  is  ex- 
ceedingly sensitive.  The  constitutional  symptoms  are  quite  sug- 
gestive of  a  deep  erysipelas. 

When  this  occurs  the  wound  should  be  opened  at  once,  care- 
fully and  thoroughly  cleansed  with  a  solution  of  corrosive  sub- 
limate 1  in  2,000,  and  lightly  packed  with  iodoform  gauze.  If 
the  subaponeurotic  cellulitis  go  on  to  suppuration,  drainage  open- 


OPERATIONS   ON    THE   SCALP 


315 


ings  must  be  made  over  either  one  or  both  eyebrows,  as  is  indi- 
cated by  the  magnitude  of  the  infection,  and  the  infected  space 
washed  through  from  the  wound  (Fig.  225).  If  the  infection 
does  not  then  subside  and 
the  "  bogginess "  extends 
backward,  an  additional 
drainage  opening  should  be 
made  over  the  external  oc- 
cipital protuberance.  For 
the  purpose  tube  drainage 
(page  189,  Fig.  143)  is  the 
most  serviceable,  as  fre- 
quent through-and-through 
iavage  may  be  necessary  to 
obtain  thorough  cleansing 
of  the  infected  area.  The 
surgeon  is  admonished  not 
to  err  on  the  side  of  timid- 
ity in  these  cases,  for  the 
reason  that,  should  a  sup- 
purative periostitis  occur,  it 
is  not  a  long  step  to  inva- 
sion of  the  emissaries  of 
Santorini,  sinus  phlebitis, 
and  possibly  abscess  of  the 
brain. 

The  rubber  drainage 
tube  should  be  of  rather 
firm  rubber,  to  avoid  its 
collapse  from  pressure  of  the  tense  aponeurosis.  The  rubber  tube 
drainage  found  in  the  market  is  too  light  for  the  purpose,  and  it 
will  be  found  expedient  to  use  an  appropriately  sized  soft  rubber 
catheter  for  the  purpose. 

An  infection  of  the  skin  alone  does  not  call  for  these  severe 
measures,  as  the  skin  is  quite  firmly  attached  to  the  tissues,  and 
the  simple  packing  of  the  wound  will  suffice  the  indications. 

The  tubes  should  not  be  permitted  to  remain  in  the  anterior 
portion  of  the  scalp  any  longer  than  necessary.  If  the  drainage 
openings  are  maintained  for  a  long  time,  objectionable  scarring 


Fig.    225.  —  Rubber    Tube    Drainage    of 
Subaponeurotic  Space  of  Scalp. 


316         OPERATIONS   ON   THE   SCALP,    SKULL   AND   BRAIN 

occurs.  However,  the  possibility  of  an  unfavorable  cosmetic  out- 
come must  not  act  as  a  deterent  with  respect  to  radicalism  in  this 
connection,  for  the  reasons  stated. 

In  clean  cases  the  sutures  may  be  left  in  situ  for  five  days, 
when  they  should  be  removed. 


OPERATIONS    ON   THE   CRANIUM 

Operations  on  the  cranium  beyond  those  undertaken  for  the 
repair  of  trauma  comprise  resection  of  diseased  areas  and  inva- 
sion of  the  bone  to  provide  an  avenue  of  approach  to  the  cranial 
contents.  The  technic  of  the  two  classes  of  cases  differs  in  the 
essential  respect,  that  in  the  cases  where  the  bone  is  sectioned  for 
relief  of  disease  in  this  situation  the  bone  is  removed,  while  in  the 
last-mentioned  class  of  cases  the  bone  is  saved  and  replaced  after 
the  operation  is  completed.  Consideration  of  the  treatment  of 
fracture  of  the  skull  does  not  belong  here,  though  the  after-treat- 
ment of  wounds  in  this  connection  is  essentially  similar  to  that 
of  bone  trauma  for  the  relief  of  disease. 

When  the  cranial  bones  or  the  contents  of  the  cranium  are 
to  be  subjected  to  operative  attack,  the  preparation  of  the  scalp  is, 
in  a  general  way,  similar  to  that  described  under  the  head  of  minor 
operations  in  this  situation.  The  entire  scalp  is  shaved,  however, 
and  the  cleansing  is  performed  as  stated.  In  those  cases  in  which 
the  brain  is  to  be  made  the  object  of  manipulations,  the  landmarks 
are  designated  upon  the  shaven  scalp  (Fig.  226)  with  the  nitrate 
of  silver  stick.  The  scalp  may  be  cleansed  again  just  before  pro- 
ceeding with  the  operation  without  eradication  of  the  guides. 

I 
KROENLEIN   CONSTRUCTION 

The  illustration  shows  the  situation  of  the  fissure  of  Rolando 
and  that  of  Sylvius  according  to  the  Kroenlein  construction.  In 
instances  in  which  the  surgeon  operates  without  previously  see- 
ing the  case,  the  physician  in  charge  is  expected  to  locate  these 
two  fissures  in  the  manner  stated  before  narcosis  is  induced.  As 
a  matter  of  fact,  this  should  be  done  in  all  instances,  and  the 
patient  thus  escapes  unnecessary  prolongation  of  the  narcosis.  The 
physician  in  charge  should  acquaint  himself  with  the  method  of 


OPERATIONS   ON   THE   CRANIUM 


317 


arriving  at  these  locations  and  proceed  patiently  twenty-four  hours 
before  the  operation  to  mark  out  the  necessary  guides. 

The  following  description  is  quoted  from  Krause,  "  Surgery 
of  the  Brain  "  : 

Localization  is  most  readily  accomplished  when  the  situations  of 
the  fissures  of  Rolando  and  Sylvius  are    determined.     The    simplest 


Fig.  226. — Fissure  of  Sylvius  and  Rolando    Outlined  with  Nitrate  of  Silver. 

(Krause.) 

method  of  arriving  at  a  conclusion  in  this  regard  is  the  Kroenlein 
construction,  which  is  taken  from  his  own  illustration  and  shown  in 
Fig.  227. 

In  order  to  rapidly  locate  these  two  lines  Kroenlein  employs  a 
craniometer  made  for  himself  by  the  instrument  makers,  Hanhart  & 
Ziegler,  of  Zurich.  It  is  my  practice  to  delineate  these  lines  on  the 
shaved  scalp  twenty-four  hours  before  the  operation  with  the  nitrate 
of  silver  stick  (Fig.  226). 


318         OPERATIONS   ON  THE   SCALP,   SKULL   AND   BRAIN 

The  following  additional  lines  are  outlined  on  the  scalp : 

1.  The  base  line  (the  German  horizontal  line)  is  in  accord  with 
the  Frankfurt  agreement,  drawn  from  the  lower  rim  of  the  orbital 
cavity,  backward  through  the  highest  point  of  the  external  auditory 
meatus. 


r 

P/ 

R 

s 

tinea  horiz.  supra-orbitalis 

(Superior  horizontal)  |\ 

fie? 

MS*** 

B 

K' 

Linea  horiz.  orienlo-nrhitalis 

(German  horizontal) 

M 

Fig.  227. — Kroenlein  Construction  for  Locating  the  Central  Sulcus,  and  the 
Fissure  of  Sylvius  on  the  Surface.  K,  Division  of  fissure  of  Sylvius;  S,  Pos- 
terior end  of  fissure  of  Sylvius;  R,  Lower  end  of  central  culcus;  P,  Upper  end  of 
central  sulcus. 


OPERATIONS   ON   THE  CRANIUM  319 

2.  The  upper  horizontal  line  parallels  the  first  on  a  line  with  the 
upper  edge  of  the  orbital  cavity. 

3.  The  front  vertical  (Z)  line  runs  vertically  between  the  first 
and  second  through  the  center  of  the  zygomatic  arch. 

4.  The  middle  vertical  line  (A)  crosses  the  center  of  the  articular 
knob  of  the  inferior  maxilla. 

5.  The  posterior-vertical  line  (M)  crosses  the  posterior  edge  of 
the  mastoid  processes. 

The  linea  Rolandi  (EP)  connects  the  intersection  of  the  front 
vertical  and  the  upper  horizontal  (K)  lines  at  a  point  where  the  pos- 
terior vertical  meets  the  median  line  (P). 

The  linea  Sylvii  (KS)  halves  the  angle  (Pkk)  ;  this  is  prolonged 
backward  to  the  posterior  vertical  line.  Further  elucidation  may  be 
obtained  from  Fig.  227. 

Kroenlein  bases  his  work  on  the  observations  of  A.  Froriep,  whose 
construction  in  general  is  figured  with  respect  to  various  forms  of 
skulls,  taking  into  account  short,  high  or  long  low  forms  of  heads. 
In  the  first  class  of  cases  Froriep  thinks  the  brain  is  crowded  toward 
the  forehead  and  would  indicate  that  the  fissure  of  Bolando  lies  far- 
ther forward.  (Frontipetal  type.)  In  the  latter  class  the  brain 
appears  to  make  a  turn  upon  its  horizontal  axis  and  its  posterior  is 
crowded  backward,  constituting  a  displacement  backward  of  the  entire 
brain,  thus  causing  the  central  sulcus  to  lie  more  obliquely  backward. 
(Occipitopetal  type.)  The  same  respective  displacements  of  all 
convolution  and  fissures  occur  in  the  same  proportion.  "The  more 
marked,"  says  Froriep,  "the  length  of  the  posterior  segment  of  the 
skull  is  and  the  more  the  external  occipital  protuberance  lies  toward 
the  horizontal  or  beneath  it,  the  more  certain  may  the  occipitopetal 
type  with  a  corresponding  position  of  the  brain  be  taken  into  account. 
Per  contra  the  frontipetal  type  is  to  be  expected  when  the  audito- 
occipital  distance  is  short  and  the  posterior  segment  of  the  skull  is 
high." 

Figures  228  and  229  represent  the  two  types  as  described  by  Fro- 
riep, though  the  differences  are  quite  strongly  drawn.  The  squares 
surrounding  the  sketch  correspond  to  the  long  diameter  and  the  height 
at  the  ear  line  of  the  skull.  The  inferior  edge  of  the  orbital  cavity 
is  indicated  on  the  audi  to-orbital  line,  as  is  also  the  location  of  the 
auditory  meatus.  The  dotted  line  running  upward  at  the  latter  situa- 
tion makes  quite  apparent  the  differences  in  frontipetal  or  occipito- 
petal types  of  brains.  The  averaging  of  a  number  of  measurements 
would  indicate  that  the  most  frequent  variation  in  position  of  the 


320         OPERATIONS   ON   THE   SCALP,   SKULL  AND   BRAIN 

brain  is  that  of  rotation  on  its  transverse  axis  combined  with  dis- 
placement downward  and  backward. 

For  these  types  Froriep  emphasizes  that  "  the  total  length  of  the 
skull,  rather  than  the  longitudino-transverse  index,  indicates  the  con- 
ditions. If  the  total  length  is  beyond  a  certain  dimension  the  occipi- 
topetal  type  presents  and  per  contra,  if  this  be  below  a  certain  meas- 
urement, the  frontipetal  type  obtains.  Although  the  importance  of 
increased  vertical  diameter  is  not  to  be  disregarded,  neither  the  brachy- 


Fig.  228. — Example  of  Frontipetal  Type  of  Brain.  (Krause.)  1,  Sulcus  cen- 
tralis; 2,  Point  of  division  of  Fissure  Sylvii  (Sylvian  Point);  3,  Sulcus  centralis; 
4,  Fissure  of  Sylvius  (Upper  end);  5,  Fissure  parieto-occipitalis  (Lateral  end); 
6,  Rim  of  orbit ;  7,  External  auditory  canal ;  8,  Prot.  Occip.  Ext. ;  9,  German 
Horizontal  line. 


cephalic  nor  dolichocephalic  heads-  need  necessarily  present  the  fronti- 
petal or  occipitopetal  types  of  brain  position."  These  represen- 
tations of  Froriep  are  of  importance  to  the  surgeon,  giving  us  the 
relative  values  of  each  type  upon  which  to  base  a  method  of  action. 

Beyond  the  various  types  of  skulls  other  deviations  from  standard 
are  to  be  considered,  such  as  race,  sex  and  age.  To  avoid  encumber- 
ing elucidation  of  the  problem  I  proceed  at  once  to  a  discussion  of  the 
most  important  considerations  in  connection  with  the  convolutions 
and  fissures  of  the  brain. 

1.  The  sulcus  central  is  (fissure  of  Rolando)  generally  takes  a 
course  in  which  there  are  two  kneelike  bends;  its  situation,  therefore, 
is  only  determinable  on  the  calvarium  at  its  upper  and  lower  termina- 


OPERATIONS   ON   THE  CRANIUM 


321 


tions.  The  former  is  Located  by  dividing  in  one-half  the  distance 
between  the  root  of  the  nose  (naison)  and  the  external  occipital  pro- 
tuberance (inion)  and  measuring  backward  from  this  2  cm.  {Thane, 
1  cm.)  Broca  employs  for  the  purpose  in  addition  to  the  naison, 
which  corresponds  to  where  the  nasal  suture  reaches  the  frontal  bone, 
the  ophryon,  which  is  located  at  the  middle  of  the  glabella.  Measur- 
ing backward  from  the  ophryon  in  the  median  line  the  upper  end  of 
the  central  fissure  is  located  53/100  behind  the  former.  (E.  Masse 
and  Woolingham.)     The  lower  end  of  the  fissure  corresponds  in  the 


Fig.  229. — Example  of  Occipito  Petaler  Type  or  Brain.  (Krause.)  1,  Sulcus 
centralis;  2,  Point  of  division  of  Fissure  Sylvii  (Sylvian  Point);  3,  Sulcus  cen- 
tralis; 4,  Fissure  of  Sylvius  (Upper  end);  5,  Fissure  parieto-occipitalis  (Lateral 
end);  6,  Rim  of  orbit;  7,  External  auditary  canal;  8,  Prot.  Occip.  Ext.; 
9,  German  Horizontal  line. 


adult  to  a  point  determined  by  dropping  a  vertical  line  through  the 
preauricular  depression  between  the  tragus  and  the  articular  head  of 
the  inferior  maxilla  on  the  upper  edge  of  the  zygoma,  and  measuring 
upward  on  this  line  5  to  6  cm.  from  the  upper  edge  of  the  external 
auditory  meatus.  In  children  the  foot  of  the  fissure  is  located  15 
mm.  below  the  middle  of  a  line  drawn  vertically  from  the  external 
auditory  meatus  to  the  sagittal  line.  This  line,  together  with  the 
fissure,  forms  an  angle  of  67  degrees.     (Hare.) 

The  central  fissure  lies  in  the  middle  of  the  anterior  third  of  the 
parietal  bone;  its  lower  two-thirds  runs  nearly  parallel  to  the  coronal 
suture,  while  the  upper  one-third  deviates  sharply  backward.  The 
position  it  occupies  is  at  its  lower  end  30,  at  the  upper  40  to  50  mm. 


322         OPERATIONS   ON   THE   SCALP,   SKULL   AND  BRAIN 

from  the  coronal  suture.     In  women  the  distances  are  27  to  45  mm., 
and  in  children  11  to  33  mm.  respectively.      (Poirier.) 

As  the  -gyri  centralis  anterior  and  posterior  in  the  adult  measure 
at  their  middle  18  to  22  mm.  in  breadth,  determination  of  the  situa- 
tion of  the  central  fissure  locates  the  situation  of  the  precentral  and 
postcentral  convolutions. 

2.  The  Fissure  of  Sylvius  runs  with  moderate  ascending  obliquity 
from  Brocas'  pterion,  which  latter  is  located  near  the  posterior  end 
of  the  sphenoparietal  suture  (anterior  vertical  line  4  to  4%  cm.  above 
the  zygoma),  to  the  middle  of  the  lower  portion  of  the  parietal  tubercle, 
though  it  does  not  in  all  instances  reach  quite  to  the  latter  point. 
As  the  fissure  varies  in  development,  and  with  regard  to  its  upper 
terminal  end  also  varies  considerably  as  to  its  course,  the  designa- 
tion just  stated  is  somewhat  unreliable.  In  the  frontipetal  type 
Froriep  found  the  upper  end  of  the  fissure  more  toward  the  anterior 
lower  portion  of  the  parietal  tubercle,  and  in  the  occipitopetal  type 
more  toward  its  posterior  aspect.  In  children  during  the  first  two 
years  of  life  the  squamous  bone  is  quite  small,  and  the  parietal 
bone  reaches  to  or  extends  below  the  first  temporal  sulcus.  In  these 
instances  the  fissure  of  Sylvius  is  covered  entirely  by  the  parietal 
bone. 

The  fissure  divides  into  three  branches,  ramus,  anterior  horizon- 
talis,  ramus  anterior  ascendens  and  ramus  posterior  horizontalis.  The 
latter  represents  as  the  main  branch  the  greater  part  of  the  fissure. 
The  origin  of  the  two  anterior  branches  corresponds  to  the  punctual 
Sylvii  {Sylvian  point  of  the  English),  which  is  located  at  the  pterion. 
The  ramus  anterior  ascendens  lies  vertically  to  the  ramus  posterior 
horizontalis ;  the  ramus  anterior  horizontalis  runs  from  the  pterion 
beneath  the  sphenoparietal  suture  with  reliable  persistence  in  an  ante- 
rior direction. 

3.  The  three  frontal  convolutions  lie  with  their  posterior  ends 
in  contact  with  the  precentral  convolution,  i.  e.,  about  22  mm.  from 
the  central  fissure.  The  first  begins  1  cm.  from  the  median  line,  taking 
the  longitudinal  sinus  into  account.  The  second  is  located  with  its 
middle  (in  children,  Fere)  under  the  center  of  the  frontal  eminence, 
while  in  the  adult  this  point  corresponds  to  the  first  frontal  fissure 
or  to  the  border  between  the  inner  and  outer  two-thirds  of  the  second 
frontal  convolutions  (Poirier).  The  third  is  situated  about  the  rami 
anterior  horizontalis  and  ascendens  of  the  fissure  of  Sylvius. 

4.  The  three  lateral  temporal  convolutions  occupy  the  space  at 
the  side  of  the  brain  between  the  fissure  of  Sylvius  and  the  temporal 
border.     The  latter  in  the  average  corresponds  to  a  line  5  mm.  above 


OPERATIONS  ON  THE  CRANIUM  323 

the  upper  edge  of  the  external  auditory  meatus,  that  is,  in  this  situa- 
tion, very  near  the  level  of  the  upper  border  of  the  zygoma,  and  at 
its  middle  to  the  incisura  semilunaris  of  the  lower  jaw,  where  the 
lowest  point  of  the  temporal  lobe  is  usually  found  (A.  Froriep), 
though  it  may  dip  down  to  opposite  the  lower  edge  of  the  zygoma. 

The  first  temporal  convolution  measures  at  its  center  about  15 
mm.  in  breadth,  and  is  bounded  below  by  the  first  temporal  fissure, 
which  is,  because  it  runs  parallel  to  the  fissure  of  Sylvius,  at  times 
called  the  fissura  parallela.  The  second,  which  is  rarely  strongly 
apparent,  lies  about  in  the  middle  between  the  first  fissure  and  the 
temporal  border  line. 

The  anterior  two-thirds-  of  the  first  and  second  temporal  convolu- 
tions are  covered  by  the  squamous  portion  of  the  temporal  bone,  the 
extreme  front  ends  by  the  greater  wing  of  the  sphenoid.  The  anterior 
portion  of  the  third  (and  fourth)  temporal  convolution  may  be  reached 
from  the  anterior  part  of  the  inferior  temporal  fossa,  which  is  formed 
by  the  greater  wing  of  the  sphenoid  bone. 

All  three  lateral  temporal  convolutions  end  at  their  posterior 
aspects  in  the  gyrus  angularis  and  supra  marginalis,  both  of  which 
are  most  largely  formed  by  the  parietal  lobes. 

5.  The  location  of  the  gyrus  supramarginalis  corresponds  to  the 
situation  of  the  tuberosity  of  the  parietal  bone  {Hushe),  and  winds 
around  the  posterior  end  of  the  ramus  posterior  horizontalis  of  the 
fissure  of  Sylvius. 

6.  The  gyrus  angularis  winds  around  the  posterior  upper  end  of 
the  first  temporal  fissure.  Its  location  is  determined  upon  the  un- 
opened skull  in  its  relationship  to  the  tuberosity  of  the  parietal  bone 
lying  a  little  behind  and  above  it,  i.  e.,  about  3  cm.  behind  the  gyrus 
supramarginalis.      (Poirier. ) 

7.  The  sulcus  parietalis  (intraparietal  -fissure)  consists  of  two 
divisions;  its  ascending  branch  connects  with  the  retrocentral  fissure, 
and  lies  about  20  mm.  behind  the  central  fissure.  (Waldeyer.)  The 
longer  horizontal  branch  runs  close  to  the  upper  portion  of  the  tuber- 
cle of  the  parietal  bone,  45  mm.  lateral  to  the  median  line,  and  when 
it  reaches  to  opposite  the  lambda  it  approaches  to  within  33  mm.  of 
the  latter.      (Thane.) 

8.  The  parieto-occipital  fissure,  in  the  occipitopetal  type  of 
skull,  lies  with  its  upper  end  immediately  above  the  lambda  (top  of 
the  squamous  portion  of  the  occipital  bone)  or  corresponds  exactly 
to  this  point,  and  in  the  frontipetal  type  and  in  young  children, 
1  cm.  higher  up  and  2  cm.  lateral  from  the  horizontal  line.  The 
lambda  is,  in  the  adult,  located  6  to  7  cm.  above  the  external  occipital 

23 


324         OPERATIONS   ON   THE   SCALP,    SKULL   AND   BRAIN 

protuberance  (inion),  and  8  to  10  cm.  behind  the  upper  end  of  the 
Rolandic  fissure. 

Prolongation  of  the  lines  KS  and  KK,  of  the  Kroenlein  construc- 
tion to  the  sagittal  line,  leaves  a  space  between  it  and  the  median  line ; 
if  this  be  divided  into  three  parts  the  parieto-occipital  fissure  will  be 
found  to  correspond  to  about  the  junction  of  the  middle  and  upper 
thirds. 

A  knowledge  of  the  course  of  the  fissures  of  Rolando  and  Sylvius 
reveals  the  location  of  the  central  convolutions,  the  operculum,  the 
temporal  lobe  and  also  the  seat  of  the  frontal  and  parietal  lobes  of 
the  cerebrum.  As  the  external  occipital  protuberance  is  palpable  in 
all  skulls,  the  location  of  the  occipital  lobe  is  also  readily  recognized. 

9.  The  cerebellum,  with  its  hemispheres,  lies  in  contact  with  the 
squamous  portion  of  the  occipital  bone,  the  posterior  third  of  the  mas- 
toid process  of  the  temporal  bone,  and  rests  with  its  inferior  surface 
upon  the  foramen  magnum.  Upward  it  reaches  to  the  linea  nucha 
superior,  which  corresponds  to  the  lower  edge  of  the  transverse  sinus. 
"  The  white  substance  of  the  vermis  runs  on  a  quite  horizontal  line 
to  the  confluent  sinus."      (Waldeyer.) 

10.  The  large  basal  ganglia.  As  I  have  not  made  any  observa- 
tions and  have  had  no  experience  in  this  connection,  I  quote  Waldeyer 
verbatim :  "  My  investigations  substantiate  on  the  whole  those  of 
Fere  and  Dana,  but  to  be  exact  the  three  localization  levels  of  these 
authors  should  be  supplemented  by  three  additional  ones.  According 
to  Dana  a  frontal  level  18  mm.  behind  the  fronto-zygomatic  suture 
corresponds  to  the  anterior  end  of  the  corpus  striatum,  a  second  at 
the  posterior  border  of  the  base  of  the  mastoid  process  or  the  upper 
end  of  the  fissure  of  Rolando  corresponds  to  posterior  knee  of  the 
corpus  striatum  or  posterior  border  of  the  thalmus.  A  horizonal  level 
45  mm.  below  the  vertex  of  the  cranium  skirts  the  upper  surface  of  the 
striatum.  I  add  to  this  that  the  lower  border  of  the  cerebral  gan- 
glionic mass  corresponds  to  the  naison-horizontal  line,  its  lateral  di- 
mensions lying  between  the  middle  level  and  the  lateral  ventricle. 

The  anterior  horn  of  the  latter,  however,  lies  (according  to 
Poirier)  at  the  forehead,  6  to  7  cm.  from  the  scalp,  the  posterior  and 
inferior  horns  4  cm.  Tillaux  states  with  truth  that  the  basal  gan- 
glia, in  toto,  are  situated  above  the  external  auditory  meatus  and  that 
this  opening  corresponds  about  to  their  middle. 

Between  the  levels  mentioned  the  island  of  Reil  is  situated,  for 
the  exact  localization  of  which  additional  guides  are  necessary.  G.  D. 
Thane  locates  the  pole  of  the  island  at  the  punctum  Sylrii.  A  point 
on  the  linea  Sylvii  35  mm.  behind  this  indicates  the  posterior  end  of 


PuNCT.  ROLflNOICUM  SUP. 


BREGMA 


Lambda — 4L/ 


Nasion 


Jnion 


Fig.  230. — Location  of  the  Insula  and  Lateral  Ventricle.  Island  of  Reil. 
The  Punctum  Sylvii  designates  the  pole  of  the  island,  its  posterior  end  lies  on 
the  linea  Sylvii  35  mm.  behind  this  point.  The  shaded  outline  of  the  island 
acts  as  a  guide  to  the  basal  ganglia,  which  extend  only  slightly  beyond  it,  about  to 
the  outer  border  of  the  main  portion  of  the  lateral  ventricle.  The  lateral  ventricle 
is  outlined  by  a  dotted  line,  its  three  horns  (anterior,  posterior  and  inferior)  are  also 
indicated  in  the  same  way.  The  fissure  of  Rolando  and  Sylvius  is  indicated  with 
broken  lines.  Reid's  base  line  (horizontal  line  of  the  skull)  is  the  Frankfurter 
Linie  of  the  German  anthropologists.  It  begins  at  the  lowest  point  of  the  inferior 
edge  of  the  orbital  cavity  and  crosses  at  the  highest  point  of  the  upper  edge  of  the 
external  auditory  meatus.     (Krause.) 


325 


326         OPERATIONS    OX   THE   SCALP,    SKULL   AND    BRAIN 

the  island,  and  the  anterior  end  lies  15  mm.  in  front  of  the  punctum 
Sylvii.  The  upper  horder  runs  from  behind  in  a  curve  through  the 
upper  end  of  the  ramus  ascendens  anterior  sylvii  to  the  anterior  upper 
end,  the  lower  from  the  posterior  end  to  a  point  15  mm.  forward  from 
the  punetum  Sylvii  on  the  linea  zygomatico-lambdoidea,  the  anterior 
border  being  outlined  by  the  union  of  the  two  anterior  end  points 
mentioned.      (Fig.  230,  Krause.) 

For  the  purpose,  the  scalp  is  shaved  and  cleansed  in  the  man- 
ner stated  above.  The  physician  supplies  himself  with  a  diagram 
of  the  necessary  measurements,  and  after  placing  the  patient  in 
a  comfortable  position  proceeds  to  indicate  the  fissures  mentioned. 
This  is  the  more  accurately  done  by  the  physician  in  charge  of 
the  case,  who  has  had  the  patient  under  observation  for  some  time 
and  has  had  ample  opportunity  to  arrive  at  a  conclusion  as  to 
what  particular  type  of  skull  formation  is  being  dealt  with.  The 
outlines  of  the  fissure  are  marked  with  the  ordinary  nitrate  of 
silver  stick,  which  is  moistened  with  water  when  the  demarcation 
is  being  made.  The  scalp  should  not  be  moistened  and  the  silver 
pencil  then  applied,  for  the  reason  that  the  excess  of  water  will 
cause  the  silver  solution  to  "  run,"  streaking  the  contiguous  skin 
and  giving  rise  to  confusion  as  to  the  exact  location  of  the  fissures, 
at  the  time  of  the  operation.  Especially  is  this  to  be  borne  in 
mind,  since  faulty  streaking  does  not  become  apparent  until 
several  hours  after  application  of  the  silver  stick,  the  silver  salt 
not  becoming  black  until  oxidized. 

The  illustration  (Fig.  226)  shows  only  the  Sylvian  and  Bo- 
landic  fissures  outlined,  and,  indeed,  these  are  the  two  most  im- 
portant guides  necessary  to  cranial  operations.  However,  addi- 
tional fissures  and  sulci  may  be  outlined  in  cases  which  involve 
invasion  of  other  than  the  motor  areas,  in  the  same  way. 

CARE   OF   WOUNDS   OF   CRANIAL   BONES 

Resection  of  the  cranial  bones  either  for  removal  of  diseased 
bone  or  for  the  purpose  of  attacking  the  cranial  contents  is  in- 
variably followed  by  drainage,  the  drainage  agent  being  modified 
in  accord  with  the  character  of  the  process  for  which  relief  is 
undertaken.  As  a  rule,  textile  fabric  drainage  will  be  found  the 
most  useful.      Tuberculosis  of  cranial  bones,   suppurative  osteo- 


OPERATIONS    OX   THE   CRANIUM  327 

myelitis,  osteitis,  etc.,  when  attacked  surgically,  are  always  fol- 
lowed by  drainage. 

The  removal  of  gumma,  osteosarcoma  and  aneurism  of  the 
diploe  do  not  present  urgent  indications  for  the  employment  of 
drainage.  However,  when  there  is  much  trauma  to  the  bone,  and 
if  the  sectioning  of  the  bone  be  attended  with  considerable  oozing 
of  blood,  provision  should  be  made  for  egress  of  secretions  by  the 
introduction  of  silk-worm  gut  or  horsehair  drainage.  The  exudate 
following  operations  of  this  sort  will  accumulate  in  the  subdural 
space  if  this  precaution  be  not  taken,  and  in  some  instances  is 
sufficiently  great  in  quantity  to  cause  cerebral  pressure  and  its 
attendant  symptoms. 

The  drainage  need  not  be  maintained  for  more  than  from  three 
to  five  days,  and  will  not  interfere  very  much  with  a  favorable 
ultimate  outcome  as  far  as  the  wound  is  concerned.  Indeed,  it 
may  be  said  that  drainage  should  be  employed  in  all  cases  involv- 
ing  invasion  of  the  cranial  cavitv. 

Infected  wounds  of  the  scalp  and  cranial  bones  should  be 
dressed  every  forty-eight  hours.  The  protective  dressing  should 
consist  of  wet  gauze,  the  gauze  being  saturated  with  a  solution  of 
corrosive  sublimate  1  in  2,000.  It  conserves  drainage  to  fluff  the 
gauze  (Fig.  188,  page  223).  Capillarity  is  enhanced  and  clean- 
liness conserved  in  this  way.  The  gauze  may  be  covered  with 
rubber  tissue  or  oiled  silk  to  maintain,  as  long  as  possible,  the 
moisture,  and  prevent  soiling  of  the  bedclothes  from  contact  with 
the  wet  dressing.  Prolonged  application  of  carbolic  acid  solutions 
may  cause  gangrene,  and  this  agent  should  not  be  used  for  the 
purpose.  Cleansing  of  the  wound  at  each  sitting  should  be  made, 
with  ample  provision  for  free  discharge  of  the  cleansing  agent. 
Hydrogen  peroxid  especially  calls  for  precautions  in  this  regard. 

It  is  easy  to  see  how  the  bubbling  peroxid  of  hydrogen  might 
convey  infective  material  into  heretofore  uninvaded  areas  if  care 
be  not  exercised  to  provide  for  its  ready  egress.  This  is  most 
important  in  connection  with  wounds  involving  the  aponeurosis, 
and  especially  so  if  the  bone  and  dura  mater  have  been  sectioned. 
When  the  latter  has  been  opened,  the  entrance  of  infective  sub- 
stances between  it  and  the  pia  may  lead  to  exceedingly  dangerous 
complications,  the  infection  extending  into  the  meshes  of  the 
arachnoid  to  the  pia  and  to  the  brain  cranial  contents. 


328         OPERATIONS    OX   THE   SCALP,    SKULL   AND    BRAIN 


OPERATIONS   INVOLVING   CRANIAL   CONTENTS 

Operations  involving  invasion  of  the  cerebral  membranes  and 
tbe  cranial  contents  present  certain  problems,  the  outcome  of  com- 
plication, which  do  not  have  the  same  import  in  other  portions 
of  the  body. 

During  all  operations  upon  the  brain  care  must  be  exercised  to 
avoid  undue  pressure  upon  the  thorax  and  abdomen  which  might 
interfere  with  respiration.  The  top  of  the  table  should  be  arranged 
to  allow  of  change  of  position  on  its  transverse  axis,  so  as  to  make 
it  feasible  to  raise  the  head  of  the  patient  if  venous  bleeding  be  exces- 
sive (V.  Bergmann)  or  to  lover  the  same  in  the  event  of  syncope. 
The  operating  room  should  be  warm  (24°-28°  C).  Beyond  this  I 
lay  the  patient  upon  warm  pads  at  the  temperature  of  the  body,  and 
wrap  the  entire  body  in  woolen  blankets. 

For  operations  on  the  cerebrum,  the  patient  is  postured  with 
the  shoulders  and  thorax  raised  to  a  little  less  than  45  degrees.  If 
the  posterior  portion  of  the  head  rests  on  the  pad,  i.  e.,  when  the 
anterior  portion  of  the  skull  is  being  invaded,  the  portion  of  the  table 
upon  which  the  pelvis  rests  is  lowered  a  little  while  tbe  upper  body 
is  caused  to  rise  obliquely.  This  position  is  very  secure.  In  operating 
on  the  side  or  posterior  aspect  of  the  head  it  is  best  to  posture  the 
patient  on  his  side  and  allow  the  head  to  extend  beyond  the  edge  of 
the  table.  In  all  instances  an  assistant  holds  the  head  firmly  with  the 
fingers  apposed  to  the  jaw  and  cheeks. 

When  opening  the  posterior  cranial  fossa  the  patient  may  be  placed 
on  the  sound  side  in  such  a  manner  as  to  bring  the  shoulder  on  a  level 
with  the  edge  of  the  table,  a  posture  which  makes  readily  approachable 
the  area  of  operation.  The  head  is  held  by  an  assistant,  or,  better  still, 
may  rest  on  the  head  supporter.  In  the  case  of  fat  persons  or  those 
who  have  short  necks,  this  posture  does  not  give  sufficient  room,  and 
I  employ  it,  as  a  rule,  only  for  the  first  step  of  the  trephining,  although 
I  have  removed  tumors  of  the  acusticus  on  two  occasions  with  the 
patient  in  this  position. 

As  a  rule  the  operator  finds  it  convenient  to  be  seated  when  invad- 
ing the  cerebellum.  The  head  of  the  table  is  lowered  slightly;  head 
and  shoulders  are  permitted  to  extend  somewhat  beyond  the  back  sup- 
port, so  as  to  permit  of  ready  approach  beneath  the  posterior  occipital 
protuberance.  The  assistant  holding  the  head  turns  it  sidewise  or 
bends  it  forward,  as  the  necessities  demand.     An  assistant  is  detailed 


OPERATIONS   INVOLVING   CRANIAL  CONTENTS  329 

to  watch  the  pulse  and  respiration.  The  regions  of  the  medulla  oblon- 
gata, with  the  centers  of  respiration  and  that  of  the  heart,  are  likely 
to  be  disturbed,  indeed,  twice  I  was  compelled  to  interrupt  the  opera- 
tion for  from  ten  to  fifteen  minutes  to  permit  of  reestablishment  of 
function  in  this  connection.  The  patient  reacted  very  nicely;  how- 
ever, had  the  pulse  and  respiration  not  been  closely  observed  a  fatal 
issue  on  the  table  would  no  doubt  have  been  the  outcome.     (Krause.) 

In  instances  where  operation  is  undertaken  for  relief  of  in- 
fectious processes  within  the  skull,  dura,  and  brain,  drainage  is 
maintained  for  a  long  time,  indeed,  until  all  evidence  of  infec- 
tion has  disappeared.  It  is  best  to  err  on  the  side  of  conservatism 
in  this  connection  and  prolongation  of  the  drainage,  to  this  end, 
is  not  to  be  regarded  as  over  caution. 

The  more  modern  and  most  generally  employed  method  of 
approach  to  the  contents  of  the  cranial  cavity  involves  saving  of 
the  bone,  unless  the  intracranial  affliction  involves  by  extension  the 
bone  itself.  In  these  instances,  as  obtains  with  tuberculosis, 
gumma,  and  malignant  disease,  the  bone  must  be  sacrificed. 

In  operations  involving  the  cranial  contents  where  infection 
does  not  exist,  drainage  of  the  superficial  wound  is  usually  es- 
tablished and  left  in  situ  for  four  or  five  days.  By  this  time  the 
question  of  infection  will  be  quite  settled,  and  if  none  has  appeared, 
the  drainage  agent  may  be  removed.  If  the  cavity  in  the  brain 
tissue  resulting  from  removal  of  a  diseased  process  has  also  been 
packed  with  gauze,  this,  too,  should  be  removed  at  the  same  sitting. 
A  smaller  portion  of  gauze  may  now  be  placed  in  the  brain  cavity 
through  the  wound  of  egress  of  the  two  drains  removed,  and  this 
will  act  as  a  drain  for  both  the  deep  and  superficial  areas. 

It  is  to  be  remembered  that  the  trauma  to  the  bone  consequent 
to  osteoplastic  resection  may  cause  superficial  necrosis  of  the  edges 
of  the  flap  or  the  opposite  edge  of  the  bone.  The  inferior  angle 
of  the  bone  may,  therefore,  be  kept  open  for  a  time  after  the 
drains  have  been  removed,  with  the  view  of  encouraging  discharge 
of  the  detritis  through  this  avenue.  This  is  accomplished  by  plac- 
ing a  small  horsehair  or  silk-worm  gut  drain  into  the  point  of  exit 
of  the  gauze  drains.  As  a  rule,  gauze  drainage  in  clean  cases  need 
not  be  maintained  for  more  than  ten  days  after  the  operation. 

The  posture  of  patients  after  operations  on  the  cranium,  its 
coverings,  and  contents,  after  the  shock  has  disappeared,  should 


330         OPERATIONS   ON   THE   SCALP,   SKULL  AND   BRAIN 

contemplate  lessening  of  the  quantity  of  blood  in  that  region  and 
gravitation  of  the  cerebrospinal  fluid  away  from  the  ventricles. 
The  head  of  the  bed  should,  therefore,  be  raised.  However,  if 
the  operation  has  been  done  with  the  view  to  facilitating  discharge 
of  the  fluid  in  order  to  lessen  intracranial  pressure,  as  obtains  in 
the  decompression  operations  intended  for  the  relief  of  hydro- 
cephalus  internus,  the  discharge  of  fluid  is  enhanced  by  lowering 
the  head  of  the  patient.  Discharge  of  cerebrospinal  fluid  calls  for 
additional  precautions.  The  quantity  discharged  in  twenty-four 
hours  is  at  times  amazingly  large,  and  the  fluid  saturates  the  dress- 
ings in  a  few  hours.  Under  these  circumstances,  it  is  difficult  to 
maintain  asepsis.  Close  attention  to  detail  has  succeeded  in  pre- 
venting infection  for  several  months  in  a  certain  number  of  in- 
stances, but  this  outcome  was  attained  only  as  the  result  of  pains- 
taking effort.  The  general  condition  of  the  patient  depends  much 
upon  whether  the  discharge  of  cerebrospinal  fluid  is  free  or  not. 
This  applies,  of  course,  to  cases  in  which  the  cause  of  increase 
of  intracranial  pressure  has  not  been  removed  at  the  operation. 
Cessation  of  the  flow  is  usually  attended  with  restlessness,  head- 
ache, paralysis,  and  subconsciousness,  in  the  order  mentioned.  In 
these  instances  inspection  will  probably  reveal  interference  with 
drainage. 

The  establishment  of  permanent  drainage  is  not  properly  dis- 
cussed here.  During  the  care  of  postoperative  cerebral  prolapse, 
when  pressure  is  being  made  to  reduce  the  protrusion,  return  to  the 
normal  is  facilitated  by  permitting  the  patient  to  assume  the  sit- 
ting posture  if  there  is  no  distinct  indication  to  the  contrary.  In- 
deed, if  the  general  condition  of  the  patient  permits,  the  pressure, 
as  described  farther  on,  should  be  made  while  the  patient  is  sit- 
ting. As  a  rule,  drainage  of  the  cranial  wound  is  made  from  its 
most  dependent  portion,  and  the  posture  of  the  patient  should  take 
cognizance  of  this  with  regard  to  both  the  supine  and  sitting 
positions. 

Patients  who  have  been  subjected  to  operative  attack  in  this 
region  of  the  body  are  frequently  subconscious  or  entirely  insen- 
sible. Especial  care  must,  therefore,  be  exercised  with  respect  to 
the  excretions.  Involuntary  discharge  of  feces  and  urine  must 
be  balanced  by  scrupulous  attention  to  cleanliness,  and  the  bed 
linen  should  be  frequently  changed.      Again,  when  sensation  is 


OPERATIONS   INVOLVING   CRANIAL  CONTENTS  331 

impaired  as  the  outcome  of  central  lesions,  bed  sores  are  likely 
to  occur,  and  it  is  a  wise  plan  to  place  these  patients  upon  a  water 
bed  immediately  after  the  operation,  and  the  attendant  must  be 
admonished  to  frequently  change  the  posture  of  the  patient  and 
to  sponge  the  skin  often  with  alcohol  to  obviate  pressure  necrosis 
and  its  consequences. 

The  diet  does  not  differ  in  these  cases  from  that  usually  em- 
ployed in  postoperative  care.  It  may,  however,  be  said  that  al- 
cohol is  probably  best  omitted  for  obvious  reasons.  The  character 
of  dressings  applied  to  the  scalp  does  not  differ  from  that  described 
in  connection  with  the  care  of  wounds  generally. 

In  instances  of  operations  on  the  cranium  which  involve  in- 
vasion of  the  brain  the  problem  is  somewhat  different.  Contact 
of  antiseptic  gauze  with  the  wound  itself  should  be  avoided  in 
clean  cases.  However,  the  fact,  as  already  stated,  that  large  quan- 
tities of  cerebrospinal  fluid  are  discharged  from  wounds  of  this 
sort,  and  that  infection  may  thus  gain  access  to  the  site  of  surgical 
trauma,  suggests  that  the  outer  layer  of  gauze  would  be  well  satu- 
rated with  some  antiseptic.  For  the  purpose  5  per  cent,  iodoform 
gauze  answers  very  well,  though  its  use  is  somewhat  objectionable 
on  the  score  of  its  offensive  odor.  Gauze  soaked  in  corrosive  sub- 
limate may  be  used.  However,  a  certain  capillarity  exists  in  both 
directions,  and  prolonged  contact  of  corrosive  sublimate  solution 
with  the  skin  causes  dermatitis.  It  is  best  to  use  the  corrosive 
sublimate  gauze  dry  and  change  it  sufficiently  frequently  to  ob- 
viate its  penetration  to  the  wound  surface.  This  will  vary  in 
accord  with  the  amount  of  cerebrospinal  fluid  discharged.  It  is 
probable  that  a  change  of  the  outer  dressing  twice  daily  will  suf- 
fice the  contingencies. 

When  the  operative  procedure  is  divided  into  two  stages,  as  is 
frequently  the  case  in  large  neoplasms  of  the  brain,  the  sutures 
temporarily  holding  the  parts  in  position  should  be  removed  on 
the  fourth  day  following  the  operation,  with  the  view  of  prevent- 
ing the  occurrence  of  small  necrotic  areas  at  the  site  of  the  sutures 
which  favor  local  infection.  Infection  in  the  superficial  wound 
would  necessitate  postponement  of  the  final  measure  of  relief  until 
it  has  been  controlled,  an  occurrence  which  might  be  objectionable, 
should  urgent  symptoms  suddenly  develop  in  the  case  calling  for 
immediate  invasion  of  the  brain  tissue. 


332         OPERATIONS   ON   THE  SCALP    SKULL  AND   BRAIN 


BONE   NECROSIS 

With  respect  to  bone  necrosis  following  operations  on  the  skull, 
Krause  says: 

If  separation  of  the  periosteum  is  avoided  necrosis  of  the  bone 
rarely  occurs  in  aseptic  cases.  Bone  necrosis  is  very  likely  to  occur 
if  the  periosteum  is  widely  separated  at  the  edges  of  the  flap,  and  espe- 
cially is  it  liable  to  occur  in  purulent  processes.  In  the  latter  cases 
the  cavity  is  tamponed  and  this  causes  interference  with  nutrition  in 
the  bone.  Owing  to  the  consistence  and  thickness  of  the  cranial 
vault  demarcation  and  separation  of  necrotic  bone  areas  is  a  pro- 
longed process,  and  this  together  with  carious  degeneration  of  the 
edges  of  the  bone  sections  may  be  maintained  for  months  before  ulti- 
mate healing  takes  place.  No  general  rule  as  to  whether  removal  of 
the  diseased  bone  is  indicated  may  be  given  the  reader  for  guidance. 

Early  in  my  experience  I  had  two  cases  in  which  extensive  necrosis 
of  bone  occurred.  Both  cases  were  operated  upon  for  removal  of  the 
ganglion  of  Gasser  by  my  own  osteoplastic  flap  method  at  the  tem- 
poral region.  The  one  case  was  one  of  one-sided  resection  of  the 
ganglion,  the  osteoplastic  temporal  flap  being  fashioned  with  the  cir- 
cular saw.  (August  23,  1895.)  The  patient  had  been  subjected  to 
peripheral  trifacial  resection  at  which  time  a  certain  degree  of  hemo- 
philia was  discovered.  Owing  to  the  severe  and  persistent  bleeding 
at  the  time  of  the  intracranial  neurectomy  the  operation  lasted  three 
hours.  The  prolonged  hemostatic  manipulations  subjected  the  flap 
to  considerable  trauma  and  the  periosteum  was  largely  separated  from 
the  bone.  Replacement  of  the  flap  was  nevertheless  made.  The  other 
case  (the  second  attempt  of  the  kind  made  by  myself  in  1892),  that 
of  a  man,  aged  sixty-two,  the  intracranial  resection  of  the  second  branch 
of  the  nerve  required  chiseling  of  the  bone.  The  operation  was  per- 
formed on  both  sides  at  the  same  time,  and  owing  to  the  enfeebled 
general  condition  of  the  patient  the  second  wound  was  tamponed  for 
five  days  before  resection  of  the  ganglion  was  undertaken.  The  con- 
sequent prolonged  interference  with  nutrition  resulted  in  necrosis. 

In  these  two  cases  the  bone  necrosis  was  not  accompanied  by  fever. 
The  process  expressed  itself  in  an  edematous  swelling  of  the  skin 
flap  and  adjacent  tissues  together  with  puffiness  of  the  lower  eyelid. 
On  the  tenth  day  the  wound  was  opened  and  the  bone  flap  removed. 
The  excised  bone  showed  a  thin  layer  of  fibrinous  pus  on  its  inner  sur- 
face. The  scalp  flap  was  replaced  and  sutured,  and  drainage  intro- 
duced into  the  two  lower  angles  of  the  wound.     A  small  amount  of 


OPERATIONS    INVOLVING   CRANIAL   CONTENTS  333 

purulent  discharge  accompanied  the  healing,  which  latter  was  achieved 
without  rise  of  temperature. 

Exfoliation  of  small  portions  from  the  edges  of  the  hone  flap 
occurred  in  two  other  cases  under  my  observation.  In  neither  case 
was  interference  called  for.  The  necrotic  bone  was  eliminated  in  the 
form  of  fluid  discbarge.  The  process  was  exceedingly  protracted,  the 
fistula?  remaining  patent  for  eight  and  ten  months  respectively.  To 
prevent  occurrences  of  this  sort  the  edges  of  the  bone  flap  which  have 
been  denuded  of  periosteum  should  be  removed  with  the  biting 
forceps. 

SECONDARY  HEMORRHAGE 

The  occurrence  of  moderate  bleeding  following  operations 
upon  the  brain  is  attended  with  quite  radical  modification  of  the 
clinical  picture,  and  if  not  relieved  may  lead  to  a  fatal  outcome. 
This  may  be  illustrated  by  quoting  a  case  of  the  sort  from  Krause. 
The  patient,  a  merchant  aged  twenty-three,  who  presented  the 
symptoms  of  cerebellar  tumor,  was  subjected  to  osteoplastic  re- 
section of  the  skull.     Krause  relates  the  following: 

After  opening  the  posterior  cranial  fossa  a  cyst  was  incised,  and 
the  cavity  tamponed  with  vioform  gauze.  At  the  end  of  five  days  the 
tampon  and  the  drain  was  removed  at  which  time  no  fluid  secretion 
was  discharged.  During  the  few  days  following  the  operation  the 
marked  symptoms  of.  cerebral  compression  had  disappeared  and  the 
less  manifest  symptoms  had  much  improved ;  however,  four  days  later 
the  evidence  of  cerebral  compression  again  appeared.  When  the  dress- 
ing was  removed  a  large  quantity  of  clear  fluid  poured  from  the  lower 
right  angle  of  the  wound.  The  osteoplastic  flap  manifested  definite 
pulsation.  Despite  this  fact,  the  compression  symptoms  did  not 
diminish,  the  temperature  rose  in  the  evening  to  39.5  and  40.0. 
There  was  no  rigidity  of  the  neck,  but  dysphagia  and  subconscious- 
ness rapidly  developed.  For  these  reasons  I  felt  justified  in  opening 
two  days  later  (eleven  days  after  incising  the  cyst)  the  entire  wound. 
Clear  fluid  dripped  constantly  from  the  lower  left  corner  of  the  wound, 
and  the  osteoplastic  flap,  which  had  quite  advanced  toward  repair, 
pulsated  visibly.  While  the  skin  was  being  shaved  and  cleansed  with 
ether  a  rather  forcible  stream  of  clear  fluid  bubbled  out  of  a  grayish 
granulating  area  located  at  the  center  of  the  wound  (about  20  cm. 
in  quantity).  However,  T  regarded  it  as  proper  to  expose  the  entire 
operation  field  in  view  of  the  patient's  menacing  general  condition. 
The  osteoplastic  flap  was  rapidly  turned  down  with  the  closed  scissors. 


334         OPERATIONS    OX   THE   SCALP,    SKULL   AND    BRAIN 

The  exposed  cerebellum  appeared  normal,  its  surface  was  smooth 
and  shining  and  of  the  same  color  as  at  the  previous  operation. 
There  was  no  swelling,  softening,  necrosis  or  pus  present.  The  only 
abnormality  presented  on  the  surface  of  the  left  cerebellar  lobe  in  the 
form  of  a  slightly  jDrotruding  area  the  size  of  the  distal  phalanx  of 
the  thumb  which  was  dark  blue  in  color  and  corresponded  to  the  site 
of  the  cyst  opened  at  the  previous  sitting.  The  incision  into  the 
cerebellum  had  quite  healed  but  was  now  bluntly  separated,  exposing 
a  cavity  the  size  of  a  plum  which  Avas  tensely  filled  with  coagulated 
blood.  This  was  gently  expressed  and  the  cavity  tamponed  with  vio- 
form  gauze.  The  osteoplastic  flap  was  sutured  into  its  original  posi- 
tion. The  following  day  the  more  marked  symptoms  of  compression 
disappeared.  The  tampon  was  removed  on  the  fourth  day,  and  two 
days  later  the  sutures  were  removed. 

The  disturbance  was  evidently  due  to  the  fact  that  after  the  tam- 
pon had  been  removed  (five  days  after  the  operation)  the  cerebellar 
wound  became  glued  together,  and  bleeding  occurred  from  the  not  yet 
obliterated  vessels  in  the  cyst  wall  which  distended  the  cavity.  The 
coagulum,  acting  like  a  tumor  and  together  with  the  retained  fluid, 
provoked  the  symptoms  of  compression.  After  the  second  operation 
recovery  went  on  to  completion  without  interruption  which  was  still 
maintained  at  the  end  of  a  year  and  a  half. 

In  two  cases  of  cortical  excision  for  Jachsonian  epilepsy  it  was 
necessary  to  reopen  the  operation  wound  because  of  blood  and  fluid 
collections  which  produced  menacing  compression  symptoms.  The 
first  case  was  that  of  a  man.  aged  thirty  years,  who  was  subjected  to 
cortical  excision  on  October  15,  1902,  after  locating  the  primary  spasm 
area  witli  the  farad ic  battery  in  the  forearm,  hand  and  face  centers. 
The  operation  did  not  make  any  serious  impression  on  the  patient's 
general  condition.  The  pulse  was  regular,  quite  full  and  strong  (80). 
The  immediate  course  was  favorable,  the  drain  and  gauze  strip  being 
removed  on  the  fourth  day  and  the  sutures  three  days  later.  The  tem- 
perature reached  37.8  at  the  end  of  thirty  hours,  and  fluctuated  in  the 
neighborhood  of  37.0  until  the  eighth  day.  when  it  rose  to  38.7  degrees. 
The  evening  of  the  day  of  operation  the  pulse  rose  to  128  but  slowly 
dropped  to  92.  Simultaneously  with  the  increase  of  temperature  the 
pulse  rose  again  to  128.  There  was  no  evidence  of  meningitis,  and  the 
wound  was  healed  except  for  the  drainage  openings. 

The  patient  became  subconscious  and  complained  of  bladder  tenes- 
mus. Badiating  pains  in  the  thigh  developed  and  the  entire  right 
leg  was  markedly  weaker  than  it  had  been  during  the  latter  few  days. 
The  muscles  of  the  thigh  were  contracted.     The  evidence  of  irritation 


OPERATIONS   INVOLVING   CRANIAL  CONTENTS  335 

pointed  to  a  focus  in  the  leg  center.  On  October  23d,  under  chloro- 
form narcosis,  I  opened  the  entire  wound,  which  required  the  knife 
for  the  purpose,  owing  to  the  firm  union  already  established,  and 
turned  aside  the  osteoplastic  and  dural  flaps.  We  found  a  brownish 
red  firmly  coagulated  clot  lying  on  the  surface  of  the  brain  at  the 
upper  portion  of  the  exposed  field  by  the  side  of  which  clear  fluid 
oozed  out.  When  this  was  removed  the  corresponding  surface  of  the 
brain  glistened,  but  was  slightly  infiltrated  with  bloody  exudate.  A 
few  strips  of  iodoform  gauze  were  laid  on  the  involved  area  and  the 
dural  and  bone  flaps  replaced  after  a  small  drain  had  been  introduced. 
The  next  day  the  temperature  fell  to  37.9  degrees,  and  the  following 
day  to  37  degrees.  The  pulse  dropped  to  104.  Eestlessness  and  the 
other  symptoms  disappeared.  Eepair  of  the  wound  occurred  without 
further  complications.  The  tamponade  was  renewed  with  sterile 
gauze  every  three  days  and  continued  for  fourteen  days  (until  Novem- 
ber 7th),  at  which  time  the  bone  was  pushed  into  the  space  in  the 
skull.  As  hernia  cerebri  did  not  develop  the  bone  healed  into  place 
without  disturbing  the  normal  outline  of  the  skull.  On  December 
29th  the  patient  was  discharged. 

RETENTION   OF   CEREBROSPINAL   FLUID 

The  influence  of  retained  cerebrospinal  fluid  is  a  complication 
arising  subsequent  to  surgical  attack  upon  the  brain,  which  leads  to 
much  the  same  train  of  symptoms  related  in  Krause's  case  of  sec- 
ondary hemorrhage.  The  inference  is  when  symptoms  of  this  sort 
occur  that  either  the  drainage  has  been  interfered  with,  or  that 
drainage  was  indicated  in  cases  where  it  was  not  employed.  This 
condition  of  affairs  is  most  likely  to  occur  in  connection  with  the 
postoperative  picture  following  cases  in  which  the  intracranial 
pressure  has  for  a  long  time  been  abnormally  high,  and  relief 
immediately  following  the  operation  is,  in  a  measure,  due  to 
relief  of  tension. 

However,  the  fact  that  the  retension  of  cerebrospinal  fluid 
may  give  rise  to  symptoms  wdien  there  has  not  been  an  abnormally 
high  intracranial  pressure  is  illustrated  in  the  history  of  the  case 
here  submitted,  which  was  subjected  to  trephining  for  relief  from 
epilepsy. 

The  patient,  a  feeble  boy,  aged  twelve  years,  had  quite  overcome  the 
effects  of  excision  of  the  hand  center.  The  temperature  had  risen 
once,  on  the  evening  of  the  day  of  the  operation,  to  38.5,  the  pulse  to 


336         OPERATIONS   ON  THE   SCALP,   SKULL   AND   BRAIN 

136.  On  the  second  day  the  record  showed  temperature  37.5,  pulse, 
96.  Despite  this  the  patient  at  this  time  became  restless  and  vomited 
persistently,  although  he  had  quickly  recovered  from  the  effects  of 
chloroform  after  the  first  0|)eration.  There  was  no  interference  with 
the  movements  of  the  head,  and  indeed,  he  showed  no  symptoms  of 
meningitis.  His  appearance  was  unfavorable  and  the  general  con- 
dition so  enfeebled  that  he  did  not  retain  the  smallest  nutritive  enema. 
As  the  conditions  continued  to  grow  more  menacing  and  endangered 
life,  I  lifted,  on  the  third  day  after  the  operation  (October  27,  1907), 
the  large  osteoplastic  flap  (60-80  mm.)  and  the  dural  flap  (50-78  mm.) 
emptying  out  a  small  quantity  of  coagulum  and  a  large  amount  of 
cerebrospinal  fluid.  After  the  introduction  of  vioform  gauze  the 
dura  and  superficial  flap  were  replaced  without  suture.  The  next  day 
the  patient  retained  a  soft  boiled  egg  and  four  rectal  injections  of  100 
cm.  each.  The  color  of  the  face  improved  and  was  no  longer  green- 
ish yellow,  as  it  had  been  the  day  before.  Improvement  continued 
with  slight  fluctuations.  On  October  30th  the  flaps  were  again  lifted 
and  the  gauze  removed.  At  the  site  of  the  cortical  excision  a  single 
strip  of  gauze  was  introduced  which  was  removed  on  November  2d. 
The  dressing  continued  to  be  saturated  with  cerebrospinal  fluid  until 
November  16th.  The  flap  was  not  sutured,  but  nevertheless  healed 
in  -place  on  the  level  with  the  contiguous  skull  without  any  residual 
bulging.  On  November  29th  the  boy  was  discharged,  in  perfect  phys- 
ical and  mental  health.  Six  months  later  the  patient  reported  in 
perfect  health. 

EDEMA  AND   SOFTENING   OF  THE   BRAIN  SUBSTANCE 

Edema  and  softening  of  the  brain  substance  may  occur,  even 
in  aspetic  cases,  in  the  region  of  the  operative  field. 

These  changes  are,  as  regards  intensity,  primarily  dependent  upon 
the  extent  of  surgical  trauma.  If  the  operation  be  restricted  to  sim- 
ple cortical  excision  for  Jaclesonian  epilepsy,  the  more  or  less  extensive 
paralysis  immediately  following  the  operation  disappears  at  the  end 
of  a  few  days.  The  characteristic  disturbances  dependent  upon  re- 
moval of  a  certain  motor  center,  however,  remain.  If  traumatic 
degeneration  develop  in  the  contiguous  brain  tissue  additional  paraly- 
sis appear,  which  are  dependent  upon  involvement  of  adjacent  foci. 
The  process  is  not  necessarily  accompanied  by  systematic  manifesta- 
tions. The  symptoms  of  edema  and  softening  appear  usually,  if 
at  all  (which  is  not  frequently  the  case),  about  a  week  following  the 
operation,  and  disappear  in  a  short  time. 


OPERATIONS   INVOLVING   CRANIAL  CONTENTS  337 

Following  removal  of  tumors  the  process  is  likely  to  be  quite  ex- 
tensive, the  outcome  of  severe  trauma  to  the  brain  substance.  The 
cause  of  these  encephalitic,  edematous  softening  processes  as  they  may 
be  designated,  may  be  explained  as  follows.  The  growth  of  the  tumor 
has  exercised  a  harmful  pressure  upon  the  invaded  brain  tissue,  the 
extirpation  has  necessitated  division  of  blood  vessels  which  also  has 
robbed  the  surrounding  parts  of  nutrition.  Division  of  nerve  fibers 
always  provokes  edematous  saturation  and  swelling  in  the  region  of 
the  trauma,  as  has  been  observed  in  the  peripheral  nervous  system. 
All  these  factors  aided,  perhaps,  by'  small  hemorrhages  cause  a  condi- 
tion of  softening,  which,  in  the  majority  of  cases  of  aseptic  operations, 
is  limited  to  the  immediate  neighborhood  of  the  operative  field  and 
does  no  great  harm.  On  the  other  hand  the  process  may  extend  and 
lead  to  a  fatal  outcome,  as  shown  in  the  following  instance. 

The  patient,  a  laborer,  aged  forty-four,  was  subjected  to  operation 
March  15,  1904.  I  removed  a  cortical  glioma  from  the  lower  portion 
of  the  anterior  central  convolution  after  deligating  the  approaching 
veins,  exercising  an  area  35-39  mm.  in  diameter  and  20  mm.  in  depth. 
The  wound  in  the  brain  was  covered  with  vioform  gauze,  over  which 
the  dural  flap  was  laid.  The  osteoplastic  flap  was  replaced  and  held 
with  sutures  except  for  a  small  area. 

The  dressing  was  changed  on  March  21st.  The  wound  was 
healthy  and  the  gauze  strips  were  removed.  The  general  condition 
of  the  patient  was  satisfactory.  On  March  29th  the  scar  was  normal, 
but  a  pulsating  prolapse  the  size  of  a  walnut  protruded  from  the  ante- 
rior inferior  angle  of  the  incision.  The  patient  stated  that  on  this 
day  the  movements  of  the  right  leg  were  less  certain  and  weaker  than 
immediately  after  the  operation.  On  April  12th  the  prolapse 
appeared  considerably  flatter.  The  general  condition  remained  good. 
Appetite  and  intestinal  functions  were  normal,  however,  the  patient 
complained  of  intermittent  headache.  From  the  29th  of  March,  on 
the  right  lower  extremity  showed  paretic  symptoms.  On  April  4th 
clonic  spasm  of  the  quadriceps  appeared.  The  asphasic  disturbances 
which  had  followed  immediately  after  the  operation  became  more 
marked,  though  the  psychic  functions  remained  normal.  The  condi- 
tions in  the  trephine  wound  continued  to  improve.  On  April  20th 
the  still  decreasing  prolapse  showed  signs  of  dermatisation  and  by 
April  26th  the  hernia  had  receded  to  the  level  of  the  surrounding  skin. 

However,  the  general  condition  of  the  patient  became  worse, 
vomiting  occurred  once.  In  the  next  few  days  the  vomiting  increased 
and  the  paralysis  increased,  though  no  spasm  occurred.  Beyond  the 
headache  no  symptoms  of  brain  pressure  developed.      Choked  disk 


338         OPERATIONS    ON   THE   SCALP,    SKULL   AND    BRAIN 

did  not  appear.  After  the  29  th  of  April  the  patient  did  not  speak 
except  to  answer  questions ;  urine  and  feces  were  passed  involuntarily. 
The  next  day  the  general  condition  was  slightly  better.  From  May 
1st  on  matters  took  on  a  worse  form,  the  left  side  of  the  body  became 
paralyzed  and  deglutition  became  difficult.  Up  to  this  time  the  pulse 
remained  below  76  and  the  temperature  normal.  May  2d  the  pulse 
was  98  in  the  morning  and  110  in  the  evening,  respiration  28  to  30. 
Death  supervened  on  the  morning  of  May  3d  after  paralytic  and  bron- 
chopneumonic  symptoms  appeared.  Vomiting  and  convulsions  did 
not  recur. 

Autopsy  showed  the  surface  of  the  brain  richly  covered  with  thick 
veins  which  quite  effectually  obscured  the  fissures.  The  sagittal  end 
of  the  left  fissure  of  Eolando  corresponded  to  a  point  1  cm.  in  front 
of  the  posterior  pole  of  the  left  cerebral  hemisphere,  which  latter 
measured,  from  its  anterior  to  its  posterior  aspects,  19  cm.     The  fis- 


frontalp-ol 


Occijtitai/iel 

Fig.  231. — Area  of  Cerebral  Softening.  (Krause.) 


sure  of  Rolando  met  at  the  point  designated  the  longitudinal  fissure. 
Two  and  a  half  centimeters  inferior  to  this  point  the  anterior  central 
convolution  presented  a  defect  which  corresponded  to  the  site  of  opera- 
tion (Fig.  231).     The  contiguous  convolutions  were  slightly  tinged 


OPERATIONS   INVOLVING  CRANIAL  CONTENTS 


339 


with  yellow.  The  irregular  anterior  border  of  the  defect  encroached 
upon  the  frontal  convolutions.  Frontal  section  disclosed  beyond  the 
defect  mentioned  the  fact  that  the  greater  part  of  the  left  cerebral 
hemisphere  was  infiltrated  with  dark  red  and  black  hemorrhages 
(Fig.  232),  which  extended  toward  the  median  line  to  near  the  longitu- 
dinal fissure  and  downward  to  the  level  of  the  fissure  of  Sylvius,  in- 
volving, however,  only  the  white  substance.  The  gray  matter  was  not 
invaded,  the  crux  was  not  involved,  and  the  process  had  extended 
between  the  cerebral  peduncles  and  the  optic  thalma,  leaving  the  basal 
ganglia  unaffected. 


r 


X.' 


Fig.  232. — Area  of  Cerebral  Softening.  (Krause.) 


It  was  evident  that  the  bleeding  had  begun  beneath  the  fissure  of 
Rolando  and  extended  throughout  the  entire  left  hemisphere,  involv- 
ing an  area  of  11  cm.  Judging  from  the  anatomical  and  microscopical 
findings  death  had  been  caused  by  hemorrhage  and  softening. 

In  some  instances  a  fortunate  discharge  of  degenerated  brain  sub- 
stance occurs  and  the  threatening  symptoms  disappear.  This  is  illus- 
trated by  the  following  case :  A  woman,  aged  thirty-seven,  had  been 
subjected  to  removal  of  a  fibrosarcoma,  the  size  of  a  mandarin,  from 
the  left  island  of  Reil.  At  the  end  of  twelve  days  following  the  enu- 
cleation, a  quite  complete  paralysis  of  the  opposite  arm  occurred, 
which  was  followed  by  paresis  of  the  lower  portion  of  the  face  and 
24 


340         OPERATIONS   ON   THE  SCALP,   SKULL  AND   BRAIN 

muscular  weakness  of  the  leg  a  few  days  later.  The  aphasia  which 
had  improved  after  the  operation  became  again  manifest,  speech  dis- 
appearing entirely.  The  involvement  of  motor  centers  contiguous  to  the 
site  of  removal  of  the  tumor  justified  the  belief  that  the  cause  of  the 
paralysis  was  either  an  edema  or  softening  of  the  respective  foci  in 
the  central  region.  In  addition,  the  patient  showed  some  evidence 
of  irritation,  headache,  pain  in  the  wound,  and  increased  pulse  rate 
(100).  Though  the  temperature  did  not  rise  sharply  the  remissions 
were  more  marked  than  had  previously  obtained.  The  consciousness 
was  dull,  though  this  cleared  up  in  a  few  clays.  The  paralysis,  how- 
ever, remained  for  several  weeks  and  gradually  cleared  up  entirely 
while  speech  returned  but  slowly.  During  this  time  the  drainage 
opening  discharged  at  first  large  quantities  of  serous  secretion  together 
with  disintegrated  particles  of  brain  substance,  which  gradually  les- 
sened in  amount. 

This  observation  would  seem  to  teach  that  a  policy  of  non-inter- 
ference together  with  close  espionage  of  the  manifestations  is  justifi- 
able. Every  attack  upon  the  brain,  indeed,  the  comparatively  simple 
reoi3ening  of  the  osteoplastic  wound  involves  additional  trauma  to 
and  pressure  upon  the  brain  substance,  which  may  cause  softening. 
On  the  other  hand  the  discharge  of  disintegrated  brain  substance  was 
manifestly  of  benefit  in  this  case.  Much  experience  and  some  good 
fortune  are  requisite  to  enable  the  observer  to  determine  what  is  best 
in  a  given  case. 

This  sort  of  superficial  necrosis  of  brain  substance  contiguous  to 
tumors  has  been  but  rarely  encountered  by  the  writer.  They  are  not 
of  importance,  and  will  be  discharged  spontaneously  provided  the 
avenue  of  egress  be  of  sufficient  dimensions.  A  secondary  operation 
may,  however,  be  requisite  if  the  necrosis  occur  beneath  a  healed  tre- 
phine opening,  and  the  process  have  not  created  a  mode  of  egress  at 
some  distant  part.  In  the  case  just  mentioned  the  trephine  wound 
had  healed  except  for  a  small  opening  at  the  lower  anterior  angle  of 
the  wound,  where  the  end  of  the  gauze  tampon  had  emerged.  At  this 
place  a  fistula  remained,  which  did  not  heal  despite  the  cessation  of 
the  discharge  of  brain  substance  and  a  small  thin  drainage  tube  was 
inserted.  Eemoval  of  the  drainage  tube  was  followed  in  a  few  hours 
by  clonic  contraction  of  the  muscles  of  the  opposite  side  of  the  face 
and  hand  and  forearm.  At  the  same  time  the  patient  who.  up  to  this 
time,  had  been  entirely  free  from  symptoms,  became  restless  and  com- 
plained of  headache,  which  originated  from  the  site  of  the  trephine 
opening.  When  the  drain  was  re-inserted  a  few  drops  of  thin  fluid  pus 
were  discharged,  and  the  symptoms  promptly  disappeared.   As  the  con- 


OPERATIONS   INVOLVING  CRANIAL  CONTENTS  341 

ditions  did  not  improve,  and  each  attempt  at  discontinuance  of  the 
drainage  was  followed  by  recurrence  of  the  symptoms  stated,  it  was 
concluded  that  a  necrosis  existed  in  the  direction  of  the  drainage  which 
was  located  obliquely  backward  and  upward  under  the  bone  flap.  The 
drain  entered  the  area  to  iy2  cm.  from  its  point  of  exit  at  the  anterior 
border  of  the  wound. 

Several  weeks  after  extirpating  the  tumor  I  exposed  the  bone  in  the 
direction  of  the  drain  with  an  oblique  incision,  and  made  an  opening 
in  the  corresponding  portion  of  the  bone  flap  with  the  burr  the  size 
of  a  silver  quarter  of  a  dollar.  The  bone  was  normal  in  appearance. 
The  opening  exposed  at  once  the  grayish  red  brain,  which  was  covered 
Avith  blood  vessels  of  the  arachnoid  and  pia.  (The  dura  had  been 
removed  at  the  time  of  the  operation  of  extirpation.)  Immediately 
below  and  beside  this  normal  brain  area  a  surface  the  size  of  a  finger 
nail  and  of  bluish  yellow  color  presented,  which  was  evidently  a  thin 
layer  of  necrotic  brain  tissue.  The  sound  introduced  through  the 
drainage  opening  reached  this  spot.  The  necrotic  area  was  excised, 
using  the  sound  as  a  guide,  and  the  latter  pushed  through  making  a 
counter  opening  for  drainage  at  the  posterior  aspect  of  the  original 
trephine  wound.  There  was  no  exudate  present.  Introduction  of  a 
drain  behind  and  tamponade  with  vioform  gauze  of  the  wound  ended 
the  operation  which  healed  by  granulation  in  a  few  weeks. 

It  is  evident  that  the  spontaneous  discharge  of  brain  substance  had 
not  resulted  in  removal  of  all  of  the  necrotic  area.  The  trephine 
wound  had  healed  posteriorly  and  the  resisting  osteoplastic  flap  pre- 
vented complete  separation  and  discharge  of  the  dead  tissue.  The 
fistula,  which  was  5  cm.  long,  was  too  narrow  for  the  purpose,  and 
only  after  a  free  avenue  of  approach  had  been  made  behind  did  the 
latter  heal.  If  the  technic  employed  would  not  have  accomplished 
the  desired  end,  it  would  have  been  necessary  to  split  the  bony  roof  of 
the  fistulous  tract  with  the  Giglia  saw  or  excise  a  narrow  strip  with 
the  Dahlgren  forceps. 

DISCHARGE   OF   CEREBROSPINAL  FLUID 

Cerebrospinal  fluid  constantly  trickles  from  the  surface  of  brain 
prolapse  in  considerable  quantity  and  especially  so  from  the  site  of  the 
wound  in  the  brain  itself,  saturating  the  dressings  quite  rapidly.  Tn 
one  case  of  exploratory  incision  into  the  motor  zone,  which  disclosed 
a  tumor  of  inoperable  dimensions,  the  subsequent  discharge  of  cerebro- 
spinal fluid  was  so  large  in  quantity  as  to  arouse  the  suspicion  that 
the  lateral  ventricle  had  been  invaded.  The  autopsy  performed  sev- 
eral months  later  proved  the  contrary. 


342         OPERATIONS   ON   THE  SCALP,   SKULL  AND   BRAIN 

At  times  the  amount  of  cerebrospinal  fluid  discharge  bears  a  rela- 
tionship to  the  size  of  the  hernia.  I  have  observed  variations  in  this 
connection  in  two  instances  of  trephining  for  removal  of  neoplasms 
which  proved  inoperable.  If  the  discharge  of  fluid  was  free  the  hernia 
became  perceptibly  smaller  and  less  tense.  This  always  occurred 
when  large  quantities  of  clear  fluid  had  been  thrown  off  for  several 
consecutive  days.  As  the  lateral  ventricle  had  not  been  opened  in 
either  instance  it  seems  fair  to  assume  that  at  these  times  the  edema 
had  been  relieved  by  the  discharge  of  fluid. 

(The  outflow  of  cerebrospinal  fluid  may  not  occur  even  if  large 
openings  be  made  in  the  dura,  if  there  be  no  increase  of  intracranial 
pressure  at  the  time  of  the  operation.  In  any  event  the  loss  of  cerebro- 
spinal fluid  ceases  very  soon  if  the  wound  is  sutured.  For  this  reason 
immediate  repair  of  the  wound  is  desirable.  Under  these  conditions  the 
dressing  remains  dry  and  need  not  be  changed  until  healing  takes  place. 

The  loss  of  considerable  quantities  of  cerebrospinal  fluid  influences 
to  some  extent  the  condition  of  the  patient.  Patients  complain  of 
headache,  especially  marked  at  the  posterior  aspect  of  the  cranium, 
feel  weak,  are  apt  to  hold  the  neck  rigid,  though  no  other  symptoms 
of  meningeal  irritation  appear.  Considerable  rise  of  temperature 
frequently  accompanies  the  symptoms  just  related.  When  the  dis- 
charge of  fluid  lessens  in  quantity  the  symptoms  promptly  disappear. 
I  have  also  observed  these  manifestations  (minus  rise  of  temperature), 
in  some  cases  after  extirpation  of  the  ganglion  of  Gasser,  when  the 
dura  has  been  torn  while  separating  the  upper  surface  of  the  ganglion 
because  of  firm  adherence  to  the  former.  In  these  instances  the  brain 
itself  is  not  invaded  and  the  contention  with  regard  to  the  influence  of 
loss  of  cerebrospinal  fluid  is  better  proved  than  in  operations  on  the 
brain. 

On  the  other  hand,  the  well-being  of  the  patient  depends  upon 
maintaining  the  outflow  of  cerebrospinal  fluid  as  shown  in  cases  oper- 
ated upon  for  hydrocephalus.  In  these  cases  arrest  of  the  outflow 
gives  rise  to  headache  and  other  disturbances.  In  this  connection  I 
may  state  that  considerable  rise  of  temperature  occurs  when  the  dress- 
ing becomes  dry. 

If  for  any  reason  infection  occurs,  the  trephine  wound  must  be  at 
once  freely  opened.  The  entire  diseased  brain  area  must  be  exposed 
in  order  to  determine  the  necessity  for  incising  the  brain,  enlarging 
the  opening  in  the  bone  or  of  splitting  the  dura.  All  dead  spaces 
should  be  lightly  packed  with  sterile  iodoform  gauze  and  drainage 
strips  introduced.  The  wound  should  be  kept  open  until  healthy 
granulations  ajjpear.      (Krause.) 


OPERATIONS    INVOLVING    CRANIAL    CONTENTS 


343 


BRAIN  PROLAPSE 

Sacrifice  of  the  bone,  when  the  pia  mater  is  sectioned  at  the 
same  time,  usually  means  cerebral  prolapse,  as  a  postoperative 
complication.  The  size  and  persistence  of  prolapse  depend  upon 
whether  the  operative  measure  has  relieved  the  intracranial  pres- 
sure, though  at  times  cerebral  extrusion  occurs  when  the  pressure 
is  not  above  the  normal.  Indeed,  prolapse  may  occur  when  the 
bone  has  not  been  sacrificed,  as  is  shown  in  the  case  depicted  here 
(Figs.  233-234). 


*       ■■  ll 

.., ^m 

. '■''    'Is 
1   | 

*■ 

Ilk 

|HB|      Jr    JJHBH«| 

J0 

fm 

Fig. 


233. — Cerebral    Prolapse    Following    Osteo-plastic    Resection    of   the 
Skull  for  Abscess  of  the  Brain. 


These  illustrations  were  taken  from  a  case  of  subcortical  ab- 
scess of  the  motor  region  situated  beneath  the  arm  and  leg  centers. 
The  hernia  forced  the  osteoplastic  flap  upward  and  displaced  it 
downward  as  shown  in  the  illustration  (Fig.  234).  The  denuded 
area  of  bone  is  the  portion  fashioned  into  a  flap  at  the  time  of  the 
operation.     The  bone,  which  was  separated  from  the   skin  and 


344         OPERATIONS   ON  THE  SCALP,   SKULL  AND   BRAIN 

periosteal  flap  by  the  progressive  growth  of  the  protrusion,  ne- 
crosed and  was  removed. 

The  illustrations  show  the  condition  of  affairs  six  weeks  after 
the  operation.  A  large  portion  of  the  extrusion  sloughed,  and 
separation  of  the  necrotic  tissue  was  effected  by  patiently  remov- 
ing separated  portions  at  each  dressing.     The  procedure  indulged 


Fig.  234. — Same  as  Fig.  233.      Showing  Bone  Flap  Elevated  by  Protrusion  of 

Prolapse. 


in  in  this  instance  may  be  regarded  as  indicative  of  what  is  gen- 
erally to  be  done  in  these  cases. 

~No  attempt  was  made  to  cut  away  the  prolapse.  As  Krause 
says,  "  each  trauma  to  the  cortex  of  the  brain,  in  situations  which 
possess  important  functions,  is  attended  with  paralysis,  and  should 
be  avoided  when  feasible." 

When  the  extrusion  is  cut  away  it  reappears  promptly,  and 
each  application  of  the  cautery  or  escharotic  is  followed  by  new 
protrusion. 

The  prolapse  is  but  sparsely  supplied  with  nourishment,  and 
after  a  time  spontaneous  sloughing  takes  place  to  a  considerable 
extent.     During  this  time  the  wound  must  be  kept  as  clean  as  is 


OPERATIONS   INVOLVING   CRANIAL  CONTENTS 


345 


feasible,  and  ample  drainage  provided  for.  The  dressings  should 
be  changed  twice  daily  and  sloughing  areas  removed  with  thumb 
forceps  or  by  the  gentle  use  of  the  curet.  Bleeding  may  be  con- 
trolled by  gauze  sponge  pressure.  Nature  will  do  much  in  these 
cases  if  given  reasonable  aid.  The  reestablishment  of  the  balance 
of  pressure  is  also  of  assistance  in  ultimate  repair.  When  the 
sloughing  has  ceased  and  healthy  granulations  cover  the  mass,  a 
surprising  reduction  in  size  of  the  prolapse  will  be  found  to  have 
taken  place. 

The  hair  should  not  be  permitted  to  grow  to  the  extent  shown 
in  the  accompanying  illustrations.  On  the  other  hand,  during  the 
time  that  the  sloughing  is  going  on  it  is  not  wise  to  subject  the 
patient  to  the  annoyance  of  keeping  the  scalp  shaved  all  the  time. 
Once  a  week  or  at  ten-day  intervals  will  suffice.     When  the  wound 


Fig.  235. — Adhesive  Plaster  Strips  and  Gauze  Tapes  for  Pressure  on  Cere- 
bral Prolapse. 


surface  is  clean,  the  scalp  may  be  kept  shaved  in  order  to  permit  of 
the  application  of  pressure.     This  may  be  attained  by  applying 

However,  patients  complain 


a  firm  bandage  over  the  dressings 


346 


OPERATIONS    ON   THE   SCALP,    SKULL   AND    BRAIN 


of  the  tightness  of  the  bandage  at  the  base  of  the  dressing,  and 
the  presence  of  the  gauze  renders  pressure  on  the  protrusion  itself 
less  effective  than  is  desirable. 

Pressure  is  effectually  attained  by  fastening  strips  of  ad- 
hesive plaster  to  the  contiguous  scalp,  at  the  central  ends  of  which 
rather  broad  tapes  are  attached  (Fig.  235).  A  flat,  thick  pad  of 
gauze  is  now  placed  upon  the  prolapse  and  the  tapes  tied  over  this, 


Fig.    236. — Gauze    Pad   Applied   to    Cerebral,   Prolapse. 
Tying  Gauze  Strips  in  Place. 


Pressure   Made    by 


making  the  required  amount  of  pressure  (Fig.  236).  The  degree 
of  pressure  may  be  standardized  by  the  behavior  of  the  case,  never 
being  sufficiently  great  to  cause  discomfort  nor  to  give  rise  to  symp- 
toms of  cerebral  pressure.  On  the  whole,  it  may  be  said  that 
operative  attempts  at  repair  should  not  be  made  until  three  months 
after  the  original  operation  unless  the  behavior  of  the  case  be  mani- 
festly so  favorable  as  to  warrant  earlier  interference.  Nature, 
time,  and  patience  will  do  much  in  this  class  of  cases.  Undue  haste 
may  do  harm. 

At  times  a  cerebral  prolapse  becomes  dermatized,  the  protru- 


OPERATIONS   INVOLVING   CRANIAL   CONTENTS 


347 


sion  being  still  considerably  elevated  above  the  skull  level.  This, 
of  course,  obtains  when  the  bone  has  been  sacrificed.  The  protru- 
sion is  then  called  a  hernia  cerebri,  in  contradistinction  to  prolapse, 
which  latter  term  should  be  applied  to  protrusions  of  brain  not 
covered  by  any  tissue. 

Fig.  237  shows  a  case  of  moderate  hernia  cerebri  following 


Fig.    237. — Cerebral,    Hernia    Following    Resection    of    the    Skull. 

(Krause.) 


osteoplastic  resection  of  the  skull  for  enucleation  of  a  cerebral 
tubercular  form.  This  is  a  fair  sample  of  the  ultimate  outcome  in 
this  class  of  cases,  though  in  a  certain  number  of  cases  no  deforma- 
tion of  the  cranial  outline  persists.  If  the  patient  feels  any  dis- 
comfort or  apprehension  at  the  presence  of  the  hernia,  it  may  be 
protected  by  the  wearing  of  a  truss,  though  this  will  only  rarely 
be  found  necessary. 


348         OPERATIONS   ON  THE  SCALP,   SKULL   AND   BRAIN 


THE   RETAINING  BANDAGE 

Following  operations  on  the  scalp,  cranium,  and  contents,  the 
retaining  bandage  is  applied  in  the  form  of  a  cap  made  up  of  prop- 
erly adjusted  roller  bandages.  Covering  of  the  entire  skull  with 
the  dressing  is  cumbersome,  and  when  the  operation  has  been  lim- 
ited to  removal  of  growths  of  the  scalp,  the  dressing  for  the  first 
twelve  hours  following  may  consist  of  a  liberal  amount  of  gauze 
held  in  place  with  the  roller  bandage.  However,  the  oozing  of 
secretions  will  have  ceased  by  this  time,  and  the  wound  may  now 
be  sealed  with  a  mixture  of  iodoform  and  collodion,  a  half  dram 


Fig.  238. — Single  Roller  Bandage  of  the  Head.  Beginning  in  the  median  line 
the  surgeon  lays  each  succeeding  turn  of  the  bandage  a  little  further  to  the  right  or 
left.     (Foote.) 

to  the  ounce,  or  aristol  may  be  substituted  for  the  iodoform  if  the 
odor  of  the  latter  is  offensive. 

The  ether  holding  the  guncotton  in  solution  evaporates  and 
leaves  the  latter,  holding  the  antiseptic  confined  in  its  meshes,  in 
contact  with  the  wound.     The  application  holds  the  stitches  firmly 


OPERATIONS   INVOLVING   CRANIAL  CONTENTS 


349 


enmeshed,  and  may  be  left  in  this  way  for  six  days  without  inter- 
ference. Remembering  that  the  guncotton  is  soluble  in  ether,  it  is 
only  necessary  to  apply  the  latter  to  the  surface,  and  the  mixture 
of  collodion,  antiseptic  powder,  and  a  small  amount  of  bloody 
secretion  is  readily  removed,  permitting  of  withdrawal  of  the 
sutures  without  causing  pain  to  the  patient.  When  the  stitches 
have  been  removed,  the  wound  may  be  again  coated  with  the 
collodion-iodoform  or  collodion-aristol  mixture,  and  the  ultimate 
repair  will  take  place  beneath  this  protection  without  further 
attention. 

When  the  operation  is  of  greater  magnitude,  the  dressing  is 
held  in  place  with  roller  bandages  which  cover  the  entire  skull.  A 
two-inch  bandage  is  used  for  the  purpose.  The  single  roller  may 
be  employed  and  is  applied  in  the  manner  shown  in  Figs.  238 


Fig.   239. 


-Single   Roller   Bandage   of  the   Head   Completed. 
(Foote.) 


and  239.  The  double  roller  is  best  used  where  it  is  desirable  to 
make  pressure  on  the  wound,  especially  in  making  compression 
following  invasion  of  the  bone.     The  mode  of  application  of  the 


350         OPERATIONS    ON   THE   SCALP,   SKULL   AND    BRAIN 

latter  form  of  bandage  is  shown  in  Figs.  240  and  241.  Frequently 
patients  who  have  been  subjected  to  operations  on  the  cranium 
and  its  contents  are,  as  already  stated,  exceedingly  restless.  The 
continuous  tossing  about  is  likely  to  loosen  the  bandage,  with  un- 
desirable results.     In  these  instances  it  is  well  to  supplement  the 


Fig.  240. — Double  Roller  Bandage  of  the  Head.  Each  circular  turn  of  the  nar- 
rower bandage  fixes  the  reverse  of  the  wider  one  on  the  forehead  and  on  the  occi- 
put.    (Foote.) 


cap  dressing  with  an  "  anchor  bandage  "  applied  in  the  way  shown 
in  Fig.  242,  which  may  be  applied  over  the  retaining  single  or 
double  roller  bandage. 

Patients  suffering  from  cerebral  irritation  frequently  pick  at 
the  dressings.  It  is  not  always  wise  to  administer  opiates  in  these 
cases,  at  least  not  in  sufficient  quantity  to  produce  unconsciousness, 
on  the  ground  that  the  symptomatology  of  the  postoperative  period 
is  masked  by  so  doing.  It  is  not  uncommon  to  see  patients  in- 
sinuate the  fingers  beneath  the  edges  of  the  roller  bandage  and 
gradually  loosen  the  strips,  ultimately  tearing  aside  the  entire 
dressing.     In  these  instances  a  cap  made  of  unbleached  muslin 


Fig.  241. — Double  Roller  Head  Bandage  Completed.     (Foote.) 


Fig.  242. — Figure  of  Eight  Bandage  of  the  Head,  Showing  Anchoring.    (Foote.) 
351 


352         OPERATIONS   ON  THE  SCALP,   SKULL   AND   BRAIN 

may  be  applied  to  the  head  and  fastened  firmly  beneath  the  occiput 
with  tape  (Fig.  243).     The  smooth  surface  of  the  cap  makes  it 


Fig.  243. — Skull  Cap  for  Delirious  Patients  Following  Operations 
on  the  Head. 

difficult  for  the  patient  to  grasp  the  dressing  and  prevents  loosen- 
ing when  the  head  is  tossed  about  npon  the  pillow. 

MASTOID   OPERATIONS 

THE    SIMPLE    OPERATION 

The  preparation  of  patients  to  be  subjected  to  operations  npon 
the  mastoid  cells  and  contiguous  tissues  does  not  materially  differ 
from  that  in  operations  in  other  situations.  It  is  to  be  remem- 
bered that  the  invasion  of  the  mastoid  cells  is  usually  undertaken 
for  the  relief  of  suppurative  inflammations,  which  suggests  that 


OPEPATIONS   INVOLVING   CRANIAL  CONTENTS  353 

the  technic  of  the  operative  procedure  should  aim  at  antisepsis 
rather  than  asepsis.  The  care  of  the  wound  is  very  similar  to  that 
which  obtains  in  infected  wounds  in  other  portions  of  the  body. 
The  wound  at  the  end  of  the  operation  is  lightly  packed  with  iodo- 
form gauze.  The  packing  should  be  made  in  such  a  way  as  to 
avoid  undue  pressure  upon  the  tissues.  Firm  pressure  for  twenty- 
four  hours  may  be  necessary  if  there  be  much  oozing  of  blood  at 
the  close  of  the  operative  procedure.  If  the  tamponade  be  firmly 
introduced  for  this  reason,  it  should  be  removed  carefully  at  the 
end  of  twenty-four  hours  and  a  new  tamponade  of  the  same  mate- 
rial introduced. 

In  this  situation,  as  in  all  others,  the  object  of  the  tamponade 
is  to  furnish  a  substance  which  will  readily  absorb  the  exudate 
and  prevent  the  accumulation  of  offensive  substances  in  the  wound. 
Firm  tamponade  prevents  the  growth  of  granulations,  interferes 
with  the  nutrition  of  the  part,  and  it  is  no  exaggeration  to  state 
that  the  patient  would,  no  doubt,  be  better  off  if  the  wound  were 
not  packed  at  all.  If  the  operation  be  the  so-called  simple  mastoid 
operation  the  tamponade  need  not  be  disturbed  for  five  or  six  days. 
The  indications  for  earlier  change  of  the  tamponade  are  excessive 
soiling  of  the  dressing  with  secretion,  pain,  fever,  or  an  offensive 
odor  (Kopetzhy).  If  the  outer  dressing  be  saturated  with  secre- 
tion, this  may  be  changed  and  the  dressing  immediately  contiguous 
to  the  wound  be  left  undisturbed,  unless  one  or  more  of  the  indi- 
cations mentioned  be  present. 

When  the  dressing  is  ultimately  changed  the  iodoform  gauze 
is  loosened  with  peroxid  of  hydrogen  and  carefully  removed  with 
the  view  of  obviating  undue  trauma  to  the  newly  formed  granu- 
lation tissue. 

The  general  surgical  principle  of  keeping  a  wound  free  from 
foreign  substances  should  be  conserved  here,  too.  The  gauze  tam- 
ponade should  become  progressively  less  bulky,  and  when  the 
granulations  reach  the  skin  surface  be  omitted  entirely.  Disregard 
of  this  rule  will  cause  the  existence  of  an  offensive  condition  of 
affairs  lasting  over  a  long  period  of  time  and,  in  the  opinion  of 
the  writer,  is  frequently  responsible  for  the  unfavorable  cosmetic 
effect  which  so  often  follows  mastoid  operations.  It  is  suggested 
that  the  ear  specialist  apply  general  surgical  rules  to  the  class  of 
cases  wTith  which  he  comes  in  contact. 


354         OPERATIONS    OX   THE   SCALP,    SKULL   AND    BRAIN 

The  after-treatment  of  cases  treated  without  tamponade.  After 
the  wound  is  thoroughly  cleansed,  the  cavity  is  insufflated  with 
boric  acid  powder.  KopetzTcy  uses  aristol  for  the  purpose,  but 
places  a  small  gauze  drain  into  the  meatal  orifice.  He  reports 
good  results  from  the  measure.  The  advantage  of  this  procedure 
is  that  the  changes  of  dressing  are  quite  devoid  of  pain,  also  that 
granulation  is  not  retarded. 

In  cases  where  epidermization  is  tardy  and  no  local  impediment 
to  its  advancement  is  to  be  found,  Bondy  obtains  good  results  from  the 
local  application  of  concentrated  etherial  solution  of  picric  acid  (1.0- 
10.0).  The  mixture  is  applied  after  the  parts  are  thoroughly  cleansed. 
Its  disadvantage  lies  in  the  intense  pain  caused  by  the  application. 
This,  however,  ceases  as  soon  as  the  ether  has  evaporated.  To  hasten 
evaporation,  air  is  blown  into  the  wound.  This  treatment  is  adminis- 
tered every  second  day.  and  during  the  intervals  the  wound  is  kept 
dry  by  insufflations  of  boracic  acid  or  clermatol. 

When  this  plan  is  adopted  the  wound  secretions  rapidly  lessen  in 
amount,  and  exuberant  granulations  disappear,  while  the  wound  sur- 
face rapidly  becomes  covered  by  epithelium. 

In  a  certain  number  of  cases,  after  thoroughly  cleansing  the  wound 
cavity,  we  have  been  very  successful  in  checking  exuberant  granula- 
tions \yj  applying  orthochlorphenol,  followed  by  absolute  alcohol ;  but 
in  the  majority  of  our  cases  we  simply  change  the  soiled  for  a  clean 
dressing,  and  kept  the  wound  surface  dry.  This  has  yielded  good 
results.  Very  often,  after  epidermatization  has  taken  place  on  one 
section  of  the  wound  cavity,  destruction  of  the  newly  formed  epidermis 
takes  place,  clue  to  the  action  of  the  wound  secretions  from  other  parts 
of  the  cavity.  To  prevent  this,  the  recommendation  of  Briihl, 
namely,  to  cover  the  newly  formed  epithelium  with  zinc  ointment, 
deserves  mention.  We  have  used  lanolin  with  excellent  effect  for 
similar  purposes. 

Dermatitis  of  the  meatal  orifice  or  surrounding  tissue,  often  results 
from  faulty  asepsis,  but  occasionally  this  condition  is  due  to  the  action 
of  the  secretions.  Eegarding  dermatitis,  the  deleterious  effects  of 
iodin  should  be  remembered.  "We  dispense  with  iodoform  after  the 
first  dressing,  substituting  either  plain  gauze  or  boracic  acid,  or  aristol 
insufflations.  In  children,  we  entirely  dispense  with  the  use  of  iodo- 
form gauze. 

Our  own  procedure  in  the  local  after-treatment  of  these  operations 
is  extremely  simple.  We  check  any  tendency  to  exuberant  granula- 
tions by  any  of  the  above-named  measures;  we  change  the  dressings 


OPERATIONS   INVOLVING   CRANIAL  CONTENTS  355 

every  second  da}',  and  unless  the  secretions  are  excessive,  we  wipe  the 
cavit}r  clean  with  dry  or  moist  wipes — moistened  in  normal  salt  solu- 
tion. The  tamponade  after  the  second  week  is  very  light;  usually 
in  cases  progressing  satisfactorily  we  content  ourselves  with  placing 
a  strip  of  plain  gauze  in  the  meatal  orifice,  and  extending  it  to  the 
antral  opening.  Previous  to  the  introduction  of  this  tampon,  aristol 
is  insufflated. 

When  the  secretions  are  excessive,  we  instill  hydrogen  peroxid, 
and  follow  this  with  95  per  cent,  alcohol.  This  usually  gives  satis- 
factory results.  Where  granulations  are  indolent,  general  systematic 
treatment,  an  outdoor  life,  and  nutritious  diet  are  indicated,  together 
Math  the  local  application  of  Peru  and  castor  oil  in  equal  parts.  One 
or  two  applications  of  the  latter  are  usually  sufficient  to  stimulate 
indolent  granulations.     (Kopetzhy.) 

THE    RADICAL    OPERATION 

When  the  radical  operation  has  been  performed  the  introduc- 
tion of  gauze  is  limited  to  a  single  gauze  strip,  which  is  intended 
for  drainage.  The  introduction  of  firm  packing  interferes  with 
the  intent.  The  dressing  is  left  undisturbed  for  a  week.  Indeed, 
the  wound  is  treated  in  all  respects  similar  to  that  applied  to 
aseptic  cases,  except  that  the  drain  is  employed.  The  stitches  are 
removed  at  the  first  dressing.  The  dressing  is,  of  course,  removed 
if  during  the  healing  process  there  are  any  manifestations  of  ac- 
cidental infection,  in  which  event  the  wound  is  treated  as  are 
infected  wounds  in  other  situations. 

RESULTS    OF    AFTER-TREATMENT 

The  length  of  time  required  for  healing  is  different  in  every  case. 
It  is  manifestly  unfair  to  compare  the  results  obtained  from  a  pro- 
cedure which  in  itself  is  the  same,  but  which  is  employed  to  cure  dif- 
ferent diseases  in  the  temporal  bone.  In  general,  the  best  results 
are  obtained  in  from  six  to  eight  weeks.  Many  cases  are  under  treat- 
ment for  months,  and  some  for  years,  before  final  recovery  can  be 
pronounced.  This  is  especially  the  case  in  under-nourished  children 
and  in  adults  debilitated  from  general  disease,  and  it  is  an  especial 
feature  of  tuberculous  mastoiditis.  The  average  duration  of  the  after- 
treatment  is  between  three  and  four  months.     (Kopetzlcij.) 


25 


356         OPERATIONS   ON  THE  SCALP,    SKULL   AND   BRAIN 

INTRACRANIAL  NEURECTOMY 

Intracranial  neurectomy,  i.e.,  removal  of  the  ganglion  of  Gasser 
involves  much  the  same  problem  as  regards  preparation  of  the 
field  of  operation  and  the  local  after-treatment  as  obtains  with 
the  problem  of  section  of  the  skull  for  other  purposes.  These 
considerations  have  been  so  largely  entered  into  under  operations 
on  the  brain  as  not  to  need  repetition  here.  However,  it  is  per- 
haps proper  to  state  in  this  connection  that  the  bone  is  quite  fre- 
quently sacrificed  in  approaching  the  ganglion,  though  the  osteo- 
plastic resection  is  also  made  in  a  not  inconsiderable  number  of 
cases.  The  former  technic  is  less  likely  to  be  followed  by  super- 
ficial necrosis  of  bone  than  the  latter.  However,  some  necrosis 
of  the  bone  does  occur  in  either  instance.  The  evidences  of  its 
presence  and  the  care  given  the  wound  until  exfoliation  takes  place 
are  already  described,  being  in  all  regards  similar  to  those  follow- 
ing opening  of  the  cranium  for  other  purposes. 

Of  course  the  operation  is  not  undertaken  for  infection,  and 
if  tamponade  is  made,  it  is  with  the  intent  of  controlling  bleeding. 
This  argues  for  removal  of  the  tampon  at  the  end  of  forty-eight 
hours  sequential  to  the  operation.  A  small  drain  of  silk-worm 
gut  should,  however,  be  introduced  into  the  wound  at  this  sitting, 
with  the  view  of  furnishing  an  avenue  of  egress  for  the  secretions 
attendant  upon  wound  repair,  and  possibly  to  allow  of  discharge 
of  disintegrated  bone  tissue.  The  fact  that  patients  who  are  sub- 
jected to  intracranial  neurectomy  have  suffered  violent  pain  for 
extended  periods  of  time,  permits  of  the  assumption  that  anodynes 
have  been  more  or  less  employed  to  afford  relief.  Probably  a 
considerable  number  of  persons  afflicted  with  trifacial  neuralgia 
are  more  or  less  habitues  in  this  regard.  This  must  be  taken  into 
consideration  immediately  after  the  operation  and  no  radical  ef- 
fort made  to  correct  the  habit  immediately  after  the  ganglion  has 
been  removed.  This  question  has  been  taken  up  under  a  general 
head  (page  30). 

In  the  after-treatment,  the  care  of  the  eye  on  the  side  where 
the  ganglion  has  been  removed  calls  for  special  precautions.  The 
injury  to  the  sympathetic  nerve  fibers  while  the  ganglion  is  being 
resected  disturbs  the  nutrition  of  the  eyeball,  and  the  loss  of  sensa- 
tion results  in  the  accumulation  of  foreign  particles  upon  the  eye 


OPERATIONS   INVOLVING   CRANIAL   CONTENTS  357 

which  otherwise  would  be  dislodged  by  winking.  This  is  obviated 
by  suturing  the  eyelids  over  the  eyeball  for  four  or  five  days 
following  the  operation. 

During  this  time  the  eyeball  should  be  washed  off  by  syringing 
a  saturated  solution  of  boracic  acid  beneath  the  eyelids  at  frequent 
intervals.  This  should  be  done  every  four  or  five  hours  and  the 
solution  should  be  warm.  Later  than  this  a  shield  should  be  worn 
over  the  eye,  and  cleanliness  observed  for  a  long  period  of  time. 
It  would  appear  that,  until  the  nutritive  changes  are  balanced  by 
nature,  care  in  maintaining  nutrition  of  the  body  has  a  tendency 
to  prevent  the  sloughing  of  the  cornea,  due  to  alteration  in  this 
respect,  the  outcome  of  injury  to  vasomotor  nerves. 

Patients  who  have  been  subjected  to  intracranial  neurectomy 
should  be  fed  as  largely  as  is  consistent  with  the  other  indications 
manifest  after  operations  of  magnitude.  More  especially  is  this 
true  in  view  of  the  fact  that,  as  a  rule,  considerable  modification 
of  general  nutrition  will,  in  all  probability,  have  already  taken 
place,  the  outcome  of  the  protracted  suffering  from  the  neuralgia. 


CHAPTER    XVII 

OPERATIONS   ON  THE   FACE 

Rhinoplasty — Osteoplastic     rhinoplasty — Harelip     and     cleft      palate — Miscel- 
laneous  operations   in   mouth. 


The  sources  of  infection  in  operations  on  the  face,  other  than 
those  which  obtain  from  causes  necessitating  the  operation,  are 
the  hair  and  the  nasal  and  the  oral  secretions.  The  hair  of  the 
scalp  should  be  treated  in  much  the  same  manner  as  for  the  re- 
moval of  benign  growths  from  the  scalp.  The  scalp  is  anointed, 
the  day  before  the  operation,  with  olive  oil  or  vaseline  and  sham- 
pooed very  thoroughly  with  tincture  of  green  soap  for  a  few  hours 

before  the  operation.  The 
hair  is  then  wrapped  in  a 
sterile  towel.  If  the  opera- 
tion contemplates  attack  of  the 
parts  contiguous  to  the  hairy 
scalp,  the  towel  may  be  moist- 
ened with  a  solution  of  cor- 
rosive sublimate  1  in  2,000. 
The  method  of  application  of 


Fig.  244.     Applying  Aseptic  Cap.     First  Step.     (Gerster.) 
358 


OPERATIONS   ON   THE   FACE 


359 


the  towel  is  shown  in  Figs  244  and  245. 


Fig. 


Fig.  245.- 


-Applying  Aseptic   Cap. 
(Gerster.) 


Second   Step. 


246  shows  the 
towel  retained  in  place  with  a  sterile  gauze  bandage. 

In  men  the  face  should  be  shaved  a  few  hours  before  the  opera- 
tion. It  is  best  to 
have  a  barber  do  this, 
as  the  nicking  of  the 
skin  consequent  upon 
unskilled  manipula- 
tions of  the  razor  is 
conducive  to  infec- 
tion and  causes  un- 
necessary annoyance 
to  the  patient.  Oper- 
ations upon  the  fore- 
head,  eyes,  and 
cheeks  above  the  level 

of  the  nostrils  do  not  call  for  special  precautions  in  after-treat- 
ment. The  mode  of  applying  the  retaining  dressing  in  this  class 
of  cases  is  shown  in  Fig.  247. 

Following  operations  involving  the  forehead  and  the  eyelids, 

and,  indeed,  a  small 
area  of  the  cheek,  the 
bandage  is  applied  as 
shown  in  Fig.  248. 
This  form  of  bandage 
is  used  in  instances  in 
which  there  is  not 
much  trauma  at  the 
time  of  the  operation, 
such  as  removal  of  a 
superficial      sebaceous 


IfcllL^ 

p.-;--'-. 

PK^*^SHJ                            Wtr?.:  .'••  ■" 'Jff~ 

.:.. .  vm&m* 

\  X^xh.  $UF^     ~r'  'l^fci^^W! 

Fig. 


246. — Aseptic    Cap,    Held 
Sterile  Gauze  Bandage. 


in    Place    with 

{Gerster.) 


cyst  or  a 
moid  cyst 
region  of 
brow. 


small  der- 
from  the 
the     eye- 


The  operations  need  not  be  followed  by  the  elaborate  dressing 
shown  in  Fig.  247.  Each  alternate  turn  is  crossed  in  the  manner 
shown  in  the  illustration,  and  a  pin  is  ultimately  made  to  pene- 
trate all  the  layers  of  bandage  at  the  site  of  crossing.     The  ban- 


360 


OPERATIONS   ON   THE   FACE 


Fig.  247. — Dressing  for  Wounds  of  Face 
Above  Nostrils.     (Gerster.) 


dage  should  be  made  of  one 
and  a  half  inch  material. 
Gauze  is  used  for  the  pur- 
pose because  it  is  more  pli- 
able than  linen  and  will  con- 
form more  readily  to  the 
irregular  outline  of  the  parts. 
Wounds  of  the  face  heal 
rapidly,  the  outcome  of  the 
vascularity  of  the  part,  and, 
perhaps,  also  because  of  the 
presence  in  large  quantity  of 
glandular  elements  in  this 
situation,  resembling,  in 
these  regards,  the  scalp. 
The  suture  material  best  em- 
ployed in  this  portion  of  the 
body    is    horsehair    or    fine 


Fig.   248. — Bandaging  Upper  Portion  of  One  Side  of  Face.     (Foote.) 


OPERATIONS   ON  THE   FACE  361 

silk-worm  gut.  The  subcuticular  suture  is  followed  more  fre- 
quently by  suppuration  than  the  usual  interrupted  suture.  This 
is  perhaps  due  to  the  trauma  to  a  large  number  of  glandular  ele- 
ments of  the  skin,  which  are  the  habitat  of  bacteria  as  far  as  their 
ducts  are  concerned,  and  the  needle,  passing  through  them  later- 
ally, liberates  the  bacteria,  permitting  of  invasion  of  the  surround- 
ing tissue. 

A  fine  silk-worm  gut  threaded  upon  a  slender  Ilagedorn  needle, 
introduced  in  the  interrupted  method  and  tied  just  sufficiently 
tight  to  hold  the  tissues  in  apposition  without  strangulation,  will 
produce  desirable  results.  The  sutures  should  not  be  permitted  to 
remain  in  situ  longer  than  six  days,  when  they  should  be  carefully 
removed,  using  slender  scissors  for  the  purpose  and  avoiding  un- 
necessary trauma  to  the  surrounding  skin  surfaces.  The  needle 
holes  will  then  disappear  very  rapidly.  The  wound  may  then  be 
sealed  with  collodion  iodoform  or  collodion  aristol,  and  the  ultimate 
repair  takes  place  under  this  seal. 

For  some  unknown  reason,  erysipelas  is  more  frequently  a 
complication  of  wounds  of  the  face  than  obtains  in  other  situations 
of  the  body.  This  occurrence  need  not  be  regarded  as  portentious 
of  unfavorable  cosmetic  outcome.  Recovery  from  the  erysipelas 
is  usually  followed  by  a  complete  restitution  to  the  normal,  and  the 
fact  that  it  has  occurred  need  not  be  considered  a  reason  for  per- 
mitting the  sutures  to  remain  in  situ  any  longer. 

When  facial  erysipelas  occurs  as  a  postoperative  complication, 
the  sutures  may  be  removed  in  the  usual  way,  and  the  infected 
surface,  together  with  the  wound,  covered  with  a  25  per  cent, 
solution  of  ichthyol  in  collodion,  and  the  constitutional  treatment 
is  carried  out  as  usual. 

Asepsis  has  made  this  occurrence  quite  rare,  yet  it  does  occur, 
and  a  meddlesome  policy,  the  result  of  apprehension  with  respect 
to  the  wound,  is  to  be  deprecated.  The  writer  has  seen  quite 
satisfactory  ultimate  cosmetic  results  follow  the  method  of  pro- 
cedure here  indicated.  Of  course,  if  suppuration  occurs  either 
from  pyogenic  infection  or  is  due  to  the  streptococcus  of  Fehleisen 
together  with  a  pus  organism,  the  wound  is  treated  by  opening  of 
a  portion  of  the  wound,  drainage,  and  light  packing  as  indicated 
above  (page  305). 

A  sharp  rise  of  temperature   with  moderate   acceleration  of 


362  OPERATIONS    ON    THE   FACE 

pulse  rate  and  little  or  no  pain  usually  means  facial  erysipelas. 
A  moderate  rise  of  temperature,  sharp  increase  in  pulse  rate,  with 
pain  and  throbbing,  would  indicate  pus  infection.  The  former 
permits  of  conservatism  and  abstinence  from  interference  with 
respect  to  the  effort  at  immediate  union,  the  latter  calls  for  libera- 
tion of  secretions,  loosening  of  sutures,  and  drainage. 

Operations  on  the  face  involving  areas  which  are  liable  to  be 
contaminated  with  nasal  or  oral  secretions  call  for  special  precau- 
tions, both  with  respect  to  preparation  and  after-treatment.  It  is 
quite  impossible  to  render  sterile  the  secretions  from  mucous  mem- 
branes. However,  the  number  of  pyogenic  organisms  present 
may  be  reduced  to  a  minimum,  and  the  tissues  may  be  relied  upon 
to  resist  their  invasion  if  present  in  small  number. 

For  several  days  before  the  operation  the  mouth  and  nasal 
cavities  are  frequently  lavaged  with  listerine  or  a  similar  prepara- 
tion. In  the  mouth  listerine  may  be  used  undiluted  as  a  wash, 
and  this  followed  by  gargling  with  large  quantities  of  the  agent 
diluted  to  one-third  of  listerine  and  two-thirds  of  sterile  water. 
This  acts  most  largely  mechanically,  though  some  chemical  effect 
is  produced  by  the  agent.  It  is  necessary  to  use  large  quantities 
of  .the  fluid  with  the  view  of  diluting  and  perhaps  exhausting  the 
virulence  of  bacteria.  The  teeth  should  be  thoroughly  cleansed, 
preferably  by  a  dentist,  several  days  before  the  contemplated 
operation,  and  the  brush  used  frequently  until  that  time.  Cor- 
rosive sublimate  and  carbolic  acid  solutions  are  not  safe  agents 
to  use  in  this  situation. 

The  nose  is  douched  with  the  same  solution,  though  pure  lis- 
terine used  in  this  way  is  advised  against  as  being  too  irritating. 
Care  should  be  taken  in  lavaging  the  nasal  cavities  to  permit  of 
easy  egress  of  the  cleansing  solution.  If  this  precaution  be  not 
taken,  the  middle  ear  may  be  invaded  by  way  of  the  Eustachian 
tube,  and  unpleasant  complications  in  this  situation  may  develop 
as  the  result.  A  convenient  and  comparatively  safe  method  of 
lavage  of  the  nasal  cavities  is  to  introduce  from  the  mouth,  be- 
hind the  soft  palate,  a  suitably  curved  nozzle  fitted  to  the  barrel 
of  a  syringe  (Fig.  249),  which  washes  the  nasal  cavities  from 
behind,  and  the  cleansing  fluid  flows  unobstructedly  from  the  an- 
terior nares. 

If  the  secretion  in  the  nose  is  crusted,  a  saturated  solution  of 


OPERATIONS   ON   THE   FACE  363 

sodium  bicarbonate,  warmed  to  the  body  temperature  aud  intro- 
duced as  described,  will  be  found  quite  effective  in  removing  the 
incrustations.  The  comparatively  clean  mucosa  may  now  be 
freely  lavaged  with  additional  cleansing  fluid,  such  as  boric 
acid,  listerine  1  in  3,  or  the  like,  using  the  same  syringe  for  the 
purpose. 

Immediately  before  the  operation,  the  mucosa  of  the  nose  may 
be  painted  with  a  solution  of  adrenalin  1  in  3,000,  which  arrests 
the  secretion  for  a  time,  and,  indeed,  for  the  twenty-four  hours 
following  the  operation  the  mucosa  may  be  kept  contracted  in  this 
way,  effectually  limiting  the  mucous  secretions. 


Fig.  249. — Syringe  for  Cleansing  Naso-pharynx. 

This  measure  is  not  so  effective  in  the  mouth,  as  the  salivary 
secretions  come  from  glands  remote  from  the  local  influence  of  the 
adrenalin.  However,  the  salivary  secretion  may  be  lessened  by 
the  administration  of  a  small  close  of  atropin  (1-120  gr.),  and 
the  secretion  from  the  mucosa  itself  controlled  with  the  adrena- 
lin solution.  Attention  to  what  appears  like  minor  considera- 
tions of  this  sort  may  determine  the  question  of  postoperative 
infection. 

The  salivary  secretion  is  probably  sterile  as  it  emerges  from 
the  ducts  of  the  salivary  glands,  and  is  later  contaminated  as  it 
mingles  with  the  mucous  from  the  lining  membrane  of  the  mouth. 
If  the  mucosa  be  kept  clean,  the  saliva  need  not  be  regarded  as  of 
menacing  import  in  this  connection.  It  is  also  probable  that  but 
little  saliva  from  the  salivary  glands  themselves  is  secreted  at 
other  times  than  during  mastication.  A  diet  which  does  not  call 
for  the  exercise  of  this  function  is  a  logical  indulgence. 

The  sterilization  of  articles  of  diet  is  taken  up  under  sepa- 
rate head  (page  430).  In  this  connection  it  is  proper  to  state  that 
whatever  efficiency,  as  regards  nutritive  value,  food  loses  as  the 
outcome  of  sterilization  need  not  be  considered  as  an  important 
factor  when  used  for  a  short  period  of  time.     The  introduction  of 


564 


OPERATIONS   ON   THE   FACE 


food  through  the  mouth  by  means  of  sterile  apparatus  of  prehen- 
sion should,  of  course,  be  assiduously  practiced  in  all  cases  where 
the  organs  concerned  in  deglutition  are 
subjected    to   operative    attack    (page 
430). 

The  dressing  of  operative  wounds 
contiguous  to  the  nose  and  mouth  is 
held  in  place  with  some  difficulty.    For 
the  purpose  it  is  necessary  to  apply 
an  elaborate  protection,  which,  though, 
cumbersome,  and  likely  to  pro- 
voke some  rebellion  on  the  part 
of  the  patient,  should,  never- 
theless, be  applied. 

A  combination  of  head 
cap,  jaw  bandage,  and  neck 
dressing,  covered  with  rubber 
tissue,  elastic  rubber  sheeting, 
or  oiled  silk  to  obviate  satura- 
tion from  without  with  ar- 
ticles  of  diet   and   secretions, 

as  shown  in  Fig.  250,  may  be      Fig.  250. — Dressing  foe  Face  and  Neck 
,  ,  „.  .,,  .  Operation.     The  arm  sling  is  omitted 

employed.  lhe      illustration  if  neck  is  not  invaded.     (Gerster.) 

shows,  also,  the  arm  sling  and 

axillary  dressing.  The  latter,  of  course,  are  not  added  unless  the 
neck  has  been  subjected  to  operation  at  the  same  time,  and  may 
be  omitted  in  face  cases. 


RHINOPLASTY 


Rhinoplasty  should  be  preceded  by  cleansing  of  the  nasal  cavi- 
ties described  above.  The  after-treatment  relates  to  prevention  of 
tension  and  avoidance  of  infection  during  healing.  Patients  op- 
erated upon  for  correction  of  deformity  in  this  situation  will  be 
found  exceedingly  tractable  and  easily  managed,  provided,  of 
course,  the  operation  be  undertaken  when  the  patient  is  sufficiently 
advanced  in  life  to  contribute  to  the  effort  of  the  surgeon  with  in- 
telligent cooperation.  If  the  operation  be  made  under  local  an- 
esthesia, the  posture  of  the  patient  immediately  subsequent  to  the 


RHINOPLASTY  365 

operation  is  easily  indicated  and  maintained.  When,  however, 
narcosis  has  been  employed,  the  patient  must  of  necessity  be 
placed  in  the  dorsal  decubitus  for  several  hours  until  conscious- 
ness returns. 

Most  persons  who  have  been  subjected  to  narcosis  vomit. 
The  vomitus  oozes  through  the  nose  and  is  likely  to  contaminate 
the  field  of  operation.  Cases  of  this  sort  should  be  watched  by 
an  efficient  assistant,  who,  by  careful  attention  to  detail,  removes 
the  vomitus  from  the  region  of  the  wound.  When  the  vomiting 
has  ceased,  the  wound  should  be  redressed,  the  nasal  and  oral 
cavities  thoroughly  cleansed,  and  a  fresh  protective  dressing  ap- 
plied. 

In  a  considerable  number  of  cases  drainage  tubes  are  placed 
into  the  nostrils  with  a  view  of  promptly  removing  contaminating 
discharges  from  the  area  of  operation.  These  are  liable  to  be  dis- 
placed during  vomiting,  and  should  be  replaced  with  sterile  tubes 
when  this  contingency  arises. 

After  operations  on  the  nose  the  sitting  posture  should  be 
maintained  as  soon  as  feasible  for  the  purpose  of  facilitating 
drainage.  The  quantity  of  nasal  secretions  is  increased  by  the 
presence  of  drainage  material.  If  it  be  regarded  necessary  to 
employ  drainage  tubes,  an  attendant  should  very  frequently 
cleanse  the  surface  contiguous  to  the  point  of  egress  of  these 
agents. 

During  the  waking  hours  the  patient  may  be  furnished  with 
a  hand  mirror  and  a  basin  of  corrosive  sublimate  solution  (1- 
3,000).  Small  gauze  sponges  are  placed  in  the  corrosive  sub- 
limate, which  the  patient  removes  at  frequent  intervals  and  wipes 
away  the  secretion.  During  the  sleeping  hours  an  attendant 
should  be  available  for  this  purpose. 

The  tubes  are  removed  every  twelve  hours  and  replaced  with 
sterile  ones.  Tube  drainage  should  not  be  maintained  for  longer 
than  three  days  for  fear  of  pressure  necrosis.  Packing  of  the 
nostrils  for  a  protracted  period  of  time  should  be  avoided.  In- 
fection of  the  accessory  sinuses  and  cavities  may  be  the  outcome 
of  firm  packing  permitted  to  remain  in  situ.  Empyema  of  the 
antrum  of  Tlighmore,  and  infection  of  the  ethmoid  and  sphenoid 
sinus  may  result  if  these  precautions  are  disregarded. 

In  addition  to  this,  the  nasal  cavities  are  gently  lavaged  from 


366  OPERATIONS   OX  THE   FACE 

behind  with  the  syringe  shown  in  Fig.  219,  using  a  mildly  anti- 
septic solution  for  the  purpose  (potassium  permanganate  1  in 
1,000).  Tension  upon  the  sutures  is  relieved  by  immobilizing 
the  contiguous  soft  parts  with  adhesive  plaster  strips.  These 
should  be  gently  removed  daily  and  replaced  with  new  ones.  For 
this  purpose  it  is  well  to  remember  that  rubber  is  soluble  in  ether, 
and  the  plaster  strips  may  be  removed  by  the  application  of  this 
agent,  thus  avoiding  unnecessary  trauma  to  the  wound  and  an- 
noyance to  the  patient,  which  accompany  the  forcible  removal  of 
the  plaster. 

The  surroundings  of  these  patients  should  be  quiet  with  the 
view  of  avoiding  the  muscular  effort  attendant  upon  conversa- 
tion and  laughter. 

The  postoperative  diet  need  not  be  sterile  in  this  class  of 
cases.  However,  as  mastication  calls  for  the  use  of  muscles  which 
are  attached  to  the  field  of  operation,  the  diet  should  consist  of 
liquids  taken  through  a  tube  or  by  means  of  the  feeding  cup  for 
several  days  after  the  operation. 

The  patient  should  be  encouraged  to  sleep  in  the  sitting  post- 
ure, a  position  easily  maintained  by  means  of  the  bed-rest. 

It  will  be  found  advantageous  to  give  attention  to  detail,  the 
neglect  of  which  may  determine  the  outcome. 

OSTEOPLASTIC   RHINOPLASTY 

Osteoplastic  rhinoplasty,  such  as  the  Koenig  method,  demands 
patience  in  after-treatment.  The  bone  flap  may  not  unite  pri- 
marily, and,  indeed,  a  portion  of  it  may  necrose.  This  does  not 
mean  that  a  favorable  outcome  need  be  despaired  of.  A  portion 
of  the  flap,  if  it  retain  its  vitality  and  become  fixed  in  place,  will 
result  frequently  in  a  good  cosmetic  result,  though  at  the  time  of 
the  healing  process  it  looks  anything  but  indicative  of  this  out- 
come. 

In  these  cases  the  wound  must  be  kept  clean  and  the  disin- 
tegrated bone  tissue  gently  removed.  Forcible  manipulation  of 
the  parts  at  this  time  interferes  with  nutrition  and  should  be 
avoided.  The  use  of  strong  antiseptic  solution  in  this  connection 
is  unwise.  A  mild  solution  of  potassium  permanganate  (1  in 
1,000)  may  be  used.     Exuberant  granulations  should  be  treated 


HARELIP   AND   CLEFT   PALATE  367 

with  the  nitrate  of  silver  stick.  Care  should  be  exercised  in  ap- 
plying the  silver  to  avoid  trauma  to  the  white  epithelial  edge  of 
the  wound.  When  a  sinus  persists,  the  pouting  excrescent  granu- 
lation which  frequently  extrudes  from  the  opening  should  be  cut 
away  with  fine  scissors  curved  on  the  flat,  and  the  bleeding  surface 
lightly  touched  with  the  caustic  stick.  The  application  of  tinc- 
ture of  iodin  into  the  sinus  by  means  of  a  small  cotton  pledget 
wound  about  the  end  of  a  slender  probe  will  stimulate  granula- 
tions and  destroy  pyogenic  organisms.  The  application  may  be 
repeated  every  three  or  four  days  for  several  sittings. 

Hydrogen  peroxid  should  not  be  introduced  into  the  nasal 
cavities ;  the  effervescence  may  force  infective  material  into  the 
accessory  sinuses  and  the  antrum.  The  essential  factors  in  the 
after-treatment  of  wounds  in  this  situation  are  frequent  cleansing 
of  the  field  with  large  quantities  of  mildly  antiseptic  solutions, 
drainage,  avoidance  of  meddlesome  manipulations,  and  immobili- 
zation of  the  apposed  wound  surfaces. 

Resection  of  one  or  both  superior  maxilla?,  invasion  of  the  an- 
trum of  Higlimore,  and  accessory  sinuses,  such  as  the  ethmoid, 
sphenoid  and  frontal  sinuses,  demand  practically  the  same  after- 
treatment  described  with  rhinoplasty.  The  fact  that  attack  upon 
these  parts  involves  invasion  of  the  mouth,  demands  that  this 
cavity  be  given  the  same  preparation  described  under  the  gen- 
eral preparation  for  operations  on  the  face.  The  administration 
of  sterile  diet  is  essential  in  these  cases.  The  reader  is  referred 
to  the  discussion  of  this  problem  on  page  430,  et  seq. 

HARELIP   AND   CLEFT   PALATE 

Harelip  and  cleft  palate  cases  are  prepared  for  operation  in 
the  same  way  as  the  cases  discussed  above.  However,  the  pre- 
cautions with  respect  to  subsequent  cleanliness  and  the  avoidance 
of  unnecessary  disturbance  to  the  field  contiguous  to  the  wound  is 
especially  emphasized  at  this  time.  The  impracticability  of  ap- 
plying a  protective  dressing  which  is  efficient  in  these  cases  ren- 
ders them  difficult  to  manage. 

In  harelip  cases  Gerster  advises  against  the  application  of  a 
cumbersome  dressing  and  simply  dusts  the  wound  with  iodoform 
powder.     This  forms  a  paste  when  mixed  with  blood  and  secre- 


368  OPERATIONS    ON  THE   FACE 

tions,  which,  upon  drying,  makes  an  efficient  protection  to  the 
wound.  Gerster  also  deprecates  the  employment  of  strips  of  ad- 
hesive plaster  intended  to  overcome  tension.  He  regards  their 
presence,  in  infants,  as  irritating,  causing  the  little  patient  to  cry 
and  tear  asunder  the  sutures. 

In  adults  this  does,  of  course,  not  obtain,  and  a  small  square  of 
iodoform  gauze  may  be  placed  in  contact  with  the  skin  wound  and 
held  in  place  with  plaster  strips.  The  dressing  must  be  changed 
twice  daily  for  the  first  three  days.  Thereafter  a  daily  change 
of  dressing  will  suffice.  Harelip  pins  should  not  be  permitted  to 
remain  in  situ  longer  than  seven  days.  At  this  time  union  in  the 
wound  will  have  taken  place,  and  the  ulceration  consequent  upon 
the  presence  of  the  pins  will  not  have  progressed  sufficiently  to 
interfere  with  favorable  ultimate  cosmetic  outcome.  The  apposi- 
tion sutures  may  be  removed  at  the  same  time.  If  catgut  has  been 
employed  for  the  latter  purpose  it  will  have  undergone  absorption 
by  this  time.  However,  when  it  is  borne  in  mind  how  much  less 
trauma  attends  upon  the  employment  of  very  fine  silk-worm  gut 
or  horsehair,  the  use  of  catgut  in  this  class  of  cases  may  be  re- 
garded as  objectionable. 

-  In  cleft  palate  it  is,  of  course,  impossible  to  apply  the  pro- 
tective dressing.  Especial  care  should,  for  this  reason,  be  given 
to  the  preparation  of  the  mouth.  The  care  of  the  teeth  and  the 
thorough  cleansing  of  the  mouth  with  a  solution  of  potassium 
permanganate  (1  in  1,000),  frequently  applied,  should  be  indulged 
in  for  several  days  before  the  operation.  Hydrogen  peroxid  may 
be  used  for  the  purpose,  as  the  effervescence  in  the  mouth  is  not 
objectionable. 

Articles  of  diet  should  be  introduced  by  means  of  a  sterile  tube. 
The  food,  which  should  be  in  liquid  form,  is  sucked  up  through 
the  tube.  However,  in  cases  of  harelip  this  effort  makes  demand 
upon  the  muscles  of  the  lips,  and  this  is  objectionable.  In  infants 
it  is  wise  to  administer  food  through  a  catheter  passed  through 
the  nose,  for  two  days  following  the  operation. 

Adults  can  be  instructed  to  achieve  the  object  without  using 
the  lips.  It  will  be  found  quite  feasible  to  introduce  the  food  into 
the  pharynx  by  manipulating  the  tongue  against  the  palate  and 
holding  the  lips  still.  A  sterile  feeding  cup  answers  the  purpose 
very  well.     The  liquid  is  allowed  to  run  into  the  mouth  and  is 


MISCELLANEOUS    OPERATIONS   IN   MOUTH  369 

readily  swallowed  without  any  effort  upon  part  of  the  lips.  In 
this  class  of  cases  it  is  quite  justifiable  to  administer  atropin  with 
the  view  of  lessening  salivary  secretion.  The  digestive  function 
of  the  saliva  may  well  be  dispensed  with  for  the  postoperative 
period,  and  the  diet  may  be  restricted  to  articles  which  do  not  con- 
tain large  quantities  of  carbohydrates.  The  small  quantity  of 
sugar  contained  in  milk  will  be  taken  care  of  by  the  digestive  secre- 
tions in  the  intestinal  canal,  without  the  unimportant  aid  given  by 
the  saliva. 

After  operations  for  cleft  palate  the  sutures  may  remain  in 
place  until  the  tenth  day  if  no  contraindication  present.  The  ques- 
tion of  cosmetic  effect,  with  respect  to  the  stitch  holes,  does  not 
come  into  consideration  in  this  situation.  Especially  is  it  wise 
to  keep  the  sutures  in  place  for  ten  days  or  two  weeks  if  the  opera- 
tion has  comprehended  invasion  of  the  bone. 

For  the  purpose  of  holding  the  bone  in  place,  silver  wire  is 
frequently  used.  This  may  be  permitted  to  remain  in  situ  for 
several  weeks  without  untoward  manifestations  arising,  provided 
a  reasonable  degree  of  attention  be  shown  cleanliness. 

Attention  to  detail,  painstaking  observation  of  the  aseptic  and 
antiseptic  methods  of  care  of  wounds,  and  sterilization  of  articles 
of  diet,  are  necessary  to  success  in  this  class  of  cases. 

MISCELLANEOUS   OPERATIONS  IN  MOUTH 

Removal  of  a  part  of  or  the  entire  tongue,  resection  of  the  oral 
mucosa,  excision  of  the  inferior  maxilla,  and,  indeed,  other  opera- 
tions of  greater  or  lesser  magnitude  which  involve  communication 
of  the  wound  surface  with  the  mouth,  call  for  the  exercise  of  the 
directions  just  offered.  Intrabuccal  removal  of  the  tongue  for 
malignant  disease  is  rarely  limited  to  this  step.  The  general 
rule,  that  contiguous  lymph  glands  should  be  removed  at  the 
same  time,  frequently  permits  of  the  maintenance  of  dependent 
drainage  through  the  wound  in  the  neck.  This  renders  keeping 
the  mouth  wound  clean  a  comparatively  easy  matter.  Drainage 
in  this  way  should  be  maintained  until  the  mouth  wound  is  quite 
healed. 

Resection  of  the  tissues  in  the  mouth  for  gumma,  tuberculosis, 
and  benign  neoplasms,  such  as  racemose  angiomata,  do  not  com- 


370 


OPERATIONS   ON   THE  FACE 


preliend  opening  of  the  neck  in  all  instances.     In  these  cases  the 
mouth  is  kept  clean  with  some  difficulty.      However,   persistent 

cleansing,  together  with  the  precau- 
tions mentioned,  will  obviate  infec- 
tion in  the  majority  of  instances. 

It  is  true  that  the  maceration 
of  soft  parts  consequent  upon  the 
liberal  use  of  solutions  interferes 
with  healing,  and  that  wounds 
which  are  kept  dry  will  unite  pri- 
marily in  a  short  time.  However, 
the  situation  of  the  wound  and  the 
contingencies  to  which  it  is  exposed 
modify  the  technic  of  postoperative 
care  in  this  situation. 

For  the  purpose  of  cleansing  the 
mouth,  the  introduction  of  the  dis- 
infecting solution  is  best  accom- 
plished with  the  Janet-Frank  syr- 
inge, armed  with  a  soft  rubber  tube 
slipped  over  the  metal  terminal  of 
the  instrument  to  avoid  trauma  to 
the  tissues.  (Fig.  251.)  If  lavage 
be  made  by  means  of  a  glass  which 
the  patient  rests  against  the  lips, 
the  contact  of  the  fluid  with  the 
skin  before  it  gains  access  to  the 
wound  should  be  avoided.  This  is, 
of  course,  a  minor  factor,  yet  if  it 
be  true,  as  frequently  stated  in  this 
work,  that  infection  is  a  question 
of  dosage,  each  avoidable  dilution 
of  the  germicidal  quality  of  a 
cleansing  solution  should  be  avoid- 
ed. When  cleansing  the  mouth  the 
patient  is  placed  in  the  sitting  posture,  with  the  head  bent  forward 
and  the  mouth  held  wide  open.  An  assistant,  or  the  patient,  holds 
a  goodly-sized  basin  beneath  the  chin,  and  the  surgeon,  who  is 
seated  on  a  low  stool  beside  the  patient,  injects  the  cleansing  solu- 


Fig.  251. — Janet-Frank  Syringe 
Armed  with  Soft  Rubber 
Tube  for  Cleansing  Mouth 
after  Operation. 


MISCELLANEOUS   OPERATIONS   IN   MOUTH 


371 


tion  from  below  (Fig.  252).  The  solution  is  thus  permitted  to 
flow  over  the  wound  surface  and  is  readily  discharged,  thus  avoid- 
ing forcing  of  secretions  back  into  the  pharynx.  The  necessary 
amount  of  pressure  is  easily  regulated. 

A  fountain  syringe  hung  two  feet  above  the  level  of  the 
patient's  mouth  will  answer  the  purpose  very  well.  In  this  event, 
a  number  of  glass  nozzles  are  kept  constantly  submerged  in  a  jar 
filled  with  carbolic  acid  solution,  and  a  new  nozzle  is  used  at  each 


Fig.  252. — Cleansing  Patient's  Mouth  after  Operation. 


sitting.  The  advantage  possessed  by  the  syringe  is  that  the  so- 
lution is  less  apt  to  become  contaminated,  as  the  hands  come  in 
contact  only  with  portions  of  the  instrument  not  closely  applied 
to  the  wound.  Between  times  the  syringe  is  kept  immersed  in  an 
antiseptic  solution. 

Shreds  of  necrosed  tissue  are  carefully  removed  with  thumb 
forceps.  If  a  necrosed  shred  should  be  somewhat  firmly  attached 
its  separation  may  at  times  be  achieved  by  a  slightly  more  forcible 

projection  of  hydrogen  peroxid  against  the  point  of  attachment. 
26 


372  OPERATIONS   ON  THE  FACE 

After  thorough  cleansing,  the  wound  surface  may  be  lightly  dusted 
with  iodoform  powdei\  The  offensive  odor  of  this  agent  is  very 
disagreeable  to  patients.  However,  it  is  fair  to  say  that  noth- 
ing will  take  its  place,  and  its  disagreeable  qualities  had  best  be 
borne. 

Iodoform  poisoning  is  quite  likely  to  occur  when  the  agent 
is  used  in  the  mouth,  for  obvious  reasons.  Bismuth  cakes  and  is 
not  very  effective.  The  use  of  corrosive  sublimate  solutions  should 
be  avoided. 


CHAPTER    XVIII 


OPERATIONS    ON    THE    NECK 

Torticollis — Tuberculosis  of  cervical  lymph  glands — Operatians  on  larynx  and 
trachea :  intubation  of  larynx ;  tracheotomy  ;  laryngectomy ;  thyroidect- 
omy ;  exothyreopexy  ;  drainage  and  packing  of  cysts  of  the  thyroid  ; 
esophagotomy. 

The  preparation  of  the  surface  of  the  neck  for  operative  attack 
does  not  differ  in  any  essential  regard  from  that  which  obtains  in 
other  situations.  The  preliminary  care  of  the  upper  air  passages 
preceding  attack  upon  the  larynx  and  trachea  is  quite  similar  to 
that  employed  in  pre- 
paring cases  for  opera- 
tions involving  the  nose 
and  mouth  (page  362). 
The  same  conditions 
obtain  .with  respect  to 
operations  upon  the 
esophagus.  The  ques- 
tion of  diet  is  taken  up 
under  discussion  of  gas- 
trointestinal surgery. 

TORTICOLLIS 

The  subcutaneous 
division  of  the  sterno- 
mastoid  has  been  quite 
abandoned  since  the  ad- 
vent of  asepsis.  After 
suture  of  the  muscle  by 
the    open    method,    the 

Wound    Of    approach    is        FlG'  253  ;-Leet  Torticollis  Showing  Method 
1  L  or    1'  ixing    Head   in  the    Over-corrected 

closed     with     silk-WOrm  Position  after  Operation.     (Whitman.) 


373 


374 


OPERATIONS   ON   THE   NECK 


gut  sutures  and  the  neck  im- 
mobilized in  the  over-corrected 
position  (Fig.  253),  using  a 
stiff  bandage  of  starch  or  plas- 
ter-of-Paris  for  the  purpose. 
The  immobilization  is  main- 


Fig.  255. — GHssoji's  Sling  for 
Applying  Counter  Ex- 
tension to  the  Shoulder 
after  Operation  for  Tor- 
ticollis,   (von  Bergmann.) 


Fig.  254. — Manipulation  of  Xeck  and 
Massage  of  Muscles  after  Oper- 
ation for  Torticollis,  (von  Berg- 
mann.) 

tained  for  fourteen  days,  when  the 
dressing  is  removed  and  the  stitches,  if 
the j  be  of  nonabsorbable  material,  re- 
moved. If  the  catgut  has  been  used  the 
sutures  will  have  been  absorbed  by  this 
time. 

The  after-treatment  consists  of  mas- 
sage and  passive  motion  destined  to 
overcome  the  malposition  of  the  cer- 
vical vertebra?.  If  this  be  not  assidu- 
ously carried  out,  the  deformity  is 
liable  to  recur,  or,  at  least,  complete 
correction  will  not  be  attained.  The 
method  of  massaging  the  neck  muscles 
and  correction  of  the  deformity  is 
shown  in  Fig.  25-i.  The  symmetrical 
development  of  the  muscles  of  the  neck 
and  shoulder  is  conserved  by  the  use  of 
a  Glisson  sling  and  counterweight  held 
in  the  hand.  The  opposite  hand  grasps 
the  handle  of  the  pulley  rope,  and 
the  patient  raises  himself  upward  by 
his  own  muscular  efforts    (Fig.   255). 


TUBERCULOSIS   OF  CERVICAL   LYMPH   GLANDS  375 

These  manipulations  must  be  carried  on  for  a  long  period  of  time 
(months).  In  addition,  the  patient  should  be  encouraged  to  in- 
dulge in  exercises  designed  to  correct  the  deformity,  such  as  sys- 
tematic class  exercises  in  a  gymnasium  or  training  in  a  military 
school,  where  his  pride  and  a  desire  to  do  as  well  as  his  comrades 
will  stimulate  him  to  an  erect  carriage  with  the  eyes  directed 
ahead.  Rowing,  boxing,  fencing,  and  wrestling  should  be  dis- 
couraged until  the  deformity  is  quite  overcome,  on  the  ground 
that  the  muscles  previously  overdeveloped  might  be  strengthened 
beyond  the  affected  ones.  The  parent  or  friend  can  be  easily 
taught  the  proper  kind  of  manipulations  to  employ.  Patients 
should  not  be  permitted  to  carry  out  the  after-treatment  them- 
selves. The  stimulating  effect  of  companionship  and  extrinsic  in* 
terest  will  do  much  to  obviate  neglect  of  the  orders  given. 

TUBERCULOSIS   OF   CERVICAL  LYMPH   GLANDS 

The  preparation  of  the  field  of  operation  for  removal  of  tuber- 
culous lymph  glands  varies  somewhat,  depending  upon  whether 
mixed  infection,  periadenitis,  abscess  and  consequent  sinuses  exist. 
In  the  simple,  uncomplicated  cases  no  special  precautionary  prep- 
aration need  be  made,  except  that  after  the  skin  has  been  sectioned 
it  would  seem  logical  that  antiseptic  solutions  be  used  for  lavage 
of  the  deep  wound.  For  the  purpose,  a  solution  of  corrosive  sub- 
limate 1  in  2,000,  liberally  flowed  over  the  field  at  frequent  in- 
tervals, is  a  useful  measure.  The  wound  is  smeared  with  iodoform 
powder  and  drainage  established.  The  drainage  material  found 
serviceable  in  this  connection  is  silk-worm  gut  (Fig.  147),  or  at 
times  when  there  is  a  reasonable  certainty  that  primary  union  will 
be  attained  the  catgut  drain  (Fig.  149)  may  be  inserted.  The 
latter  has  the  advantage  that  it  need  not  be  removed,  and  the 
dressing  need  not  be  changed  for  eight  or  ten  days  following  the 
operation,  at  which  time  the  sutures  may  also  be  removed.  In 
cases  complicated  by  sinuses  and  mixed  infection,  the  operative 
field  should  be  cleansed  in  the  usual  way  and  the  skin  anointed 
with  a  20  per  cent,  oleate  of  mercury,  twice  daily,  for  several  days 
before  the  operation.  In  other  regards  preparation  of  the  opera- 
tive field  is  the  same  as  obtains  in  uncomplicated  cases. 

This  method    of   prepa ration,    together   with    excision   of   the 


376  OPERATIONS    ON   THE   NECK 

sinuses,  and  especial  care  with  regard  to  the  exercise  of  antisepsis, 
have  resulted  in  primary  union  in  several  instances  at  the  hands 
of  the  writer. 

Drainage  is,  of  course,  established  in  this  latter  class  of  cases, 
and  the  silk-worm  gut  or  gauze  drainage  material  employed.  The 
wound  is  dressed  at  the  end  of  forty-eight  hours  and  cleansed  with 
corrosive  sublimate  solution  1  in  2,000.  The  drain  is  removed 
at  this  time  and  a  smaller  one  inserted.  Drainage  may  be  dis- 
pensed with' at  the  end  of  another  forty-eight  hours  if  there  be  no 
indication  to  the  contrary.  Cleansing  of  the  wound  by  the  forcible 
injection  of  hydrogen  peroxid  is  especially  dangerous  in  this  situa- 
tion, as  the  deep  fascial  spaces  communicate  with  the  mediastinum 
and  the  two  pleural  cavities.  • 

The  effervescence  consequent  to  the  use  of  this  agent  may  force 
fluids  into  these  cavities.  This  applies  also  to  the  cleansing  of 
superficial  wounds  of  the  neck.  The  forcible  injection  of  cleansing 
fluids  beneath  the  platysma  may  force  its  way  beneath  this  muscle 
to  below  the  clavicle  and  down  upon  the  anterior  aspect  of  the 
chest,  where  secondary  infective  foci  have  been  known  to  develop 
as  the  result.  This  is  to  be  borne  in  mind  with  respect  to  early 
drainage  of  suppurative  inflammations  in  the  neck,  which,  if  per- 
mitted to  proliferate  to  a  considerable  extent,  will  follow  the  paths 
indicated. 

The  constitutional  after-treatment  in  these  cases  should  be 
directed  toward  the  resumption  of  nutrition  as  soon  as  feasible. 
As  soon  as  postoperative  vomiting  and  shock  have  been  obviated, 
the  feeding  by  mouth  may  be  cautiously  begun.  The  writer 
administers  rectal  feeding  at  the  end  of  twelve  hours  if  the 
vomiting  persist.  The  liability  to  infection  is  lessened  by  main- 
taining the  general  tone.  This  is  more  essential  in  this  class 
of  cases  than  obtains  in  patients  not  afflicted  with  an  exhausting 
disease. 

When  it  is  borne  in  mind  that  lung  infection  is  a  frequent, 
and  bone  infection  a  not  rare,  coexisting  condition  in  these  cases, 
the  rationale  of  the  proposition  becomes  apparent.  The  operation 
itself  is  exceedingly  exhausting  because  of  the  more  or  less  severe 
hemorrhage  consequent  to  the  attack  of  a  region  so  largely  sup- 
plied 'with  blood-vessels.  If  to  this  be  added  a  period  of  post- 
operative  starvation,    the  liability  to   a   sudden  exacerbation  of 


TUBERCULOSIS    OF   CERVICAL   LYMPH    GLANDS 


377 


latent  tuberculous  processes  in  other  situations  in  the  body  becomes 
a  menace  of  considerable  magnitude. 

The  patient  should  be  set  up  in  bed  the  day  following  the 
operation  and  the  bed  wheeled  into  the  open  air.  The  former  con- 
serves drainage,  the  latter  stimulates  the  desire  for  food,  aside 
from  whatever  therapeutic  effect  the  inhalation  of  fresh  air  may 
have.  As  soon  as  the  digestive  functions  are  reestablished,  the 
generally  accepted  method  of  feeding  in  tuberculosis  should  be 
employed. 

These  cases  for  some  reason  frequently  have  tonsillitis  follow- 
ing the  operation.  This  is 
painful  and  interferes 
with  the  taking  of  nour- 
ishment. The  writer  finds 
it  useful  to  permit  the  pa- 
tient to  take  cracked  ice 
at  frequent  intervals,  and 
in  addition  gives  sodium 
salieyl,  gr.  x,  every  two 
hours  for  six  doses,  with 
apparent  benefit.  As  a 
routine  measure  creosote 
is  given  during  the  period 
of  convalescence. 

When  extensive  resec- 
tion of  the  tissues  of  the 
neck  up  to  the  forman 
jugularis  and  down  to  the 
subclavian  has  been  made, 
the  dressing  is  applied  in 
the  manner  shown  in  Fig. 
256.  Loss  of  sensation, 
the  result  of  the  division 

of  sensory  nerves,  is  a  common  sequel  to  this  operation.  Division 
of  the  auricularis  magnus  paralyzes  sensation  in  the  external  ear. 
This,  however,  usually  returns  after  several  weeks,  the  function 
being  taken  up  by  filaments  from  the  fifth  cranial  nerve.  The 
loss  of  sensation  in  the  skin  of  the  neck  is  a  small  matter,  and  fre- 
quently is  not  noticed  by  the  patient.     Division  of  the  spinal  ac- 


Fig.  256. — Dressing  for  Extensive  Opera- 
tion on  the  Neck.    (Gerster.) 


378  OPERATIONS    ON   THE   NECK 

cessory  causes  limitation  of  motion  in  the  sternomastoid  muscle. 
This  is  at  times  distressing.  Division  of  the  cervicofacial  para- 
lyzes the  angle  of  the  mouth.  This  is  only  permanent  in  a  small 
percentage  of  cases.  These  facts  are  mentioned  in  this  connection 
with  the  view  of  obviating  unnecessary  concern  to  the  patient.  The 
removal  of  neoplasms  from  the  neck  does  not  call  for  special  prep- 
aration nor  after-treatment  other  than  obtains  in  clean  wounds  in 
other  situations.  The  general  principles  are  to  be  applied  here 
as  previously  discussed. 

Immediately  after  the  operation,  and  while  the  patient  is  still 
partially  narcotized,  care  should  be  taken  to  protect  the  protective 
dressing  from  soiling  with  expectoration  and  vomitus.  For  this 
purpose  the  attendant  covers  the  dressing  with  a  towel  firmly 
pinned  about  the  neck  and  replaces  it  with  a  clean  one  as  fre- 
quently as  necessary.  Wnen  tne  nea(i  is  tossed  about  on  the  pil- 
low the  upper  edge  of  the  protective  dressing  is  likely  to  be  dis- 
lodged, leaving  a  space  between  it  and  the  skin.  Foreign  material 
is  quite  liable  to  find  its  way  under  the  dressing  and  come  in 
contact  with  the  wound,  if  this  obtain,  unless  the  precaution  men- 
tioned is  observed. 


OPERATIONS  ON  THE  LARYNX  AND  TRACHEA 

The  preparation  of  patients  about  to  be  subjected  to  opera- 
tive invasion  of  the  air  passages  through  the  neck  involves  much 
the  same  preparatory  steps,  as  described  under  operations  on  the 
mouth  (page  362).  If  the  epiglottis  is  not  removed  the  admin- 
istration of  articles  of  diet  subsequent  to  the  operation  need  not 
be  especially  considered.  In  complete  laryngectomy,  including 
removal  of  the  epiglottis,  it  is  best  to  administer  sterile  food,  on 
the  ground  that  the  tongue  will  not  sufficiently  protect  the  wound 
surface  from  the  entrance  of  foreign  substances. 

INTUBATION  OF   THE   LARYNX 

The  treatment  following  intubation  of  the  larynx  relates 
chiefly  to  the  administration  of  food.  When  food  gains  access 
to  the  larynx,  coughing  is  provoked  and  the  tube  is  expelled.  This 
is,  perhaps,  the  greatest  objection  to  employment  of  intubation. 


OPERATIONS  ON  THE  LARYNX  AND  TRACHEA 


379 


O'Dwyer  recommends  placing  the  patient  in  the  horizontal  posi- 
tion with  the  head  hanging  over  the  edge  of  the  table  or  at- 
tendant's knee,  and  feeding  semisolid  food  with  a  spoon.  The 
position  is  shown  in  Fig.  257.     The  passage  of  a  soft  catheter 


Fig.  257. — Method  of  Feeding  Infant  after  Intubation. 


through  the  nose  or  by  the  mouth  into  the  esophagus  is  use- 
ful, but  the  strangulation  and  gagging  frequently  dislodge  the 
tube  from  the  larynx  when  the  latter  methods  are  attempted. 
The  fact  that  the  laryngeal  tube  may  be  expelled  at  any  time 
calls  for  immediate  availability  of  a  skilled  attendant  to  rein- 
troduce it. 

If  a  string  has  been  left  attached  to  the  tube,  the  patient's 
hands  should  be  confined  in  such  a  way  as  to  prevent  its  acci- 
dental withdrawal.  The  tube  should  be  changed  at  the  end  of 
twenty-four  to  forty-eight  hours.     If  dyspnea  does  not  recur  it 


380 


OPERATIONS    ON   THE    NECK 


need  not  be  reintroduced.     However,  it  will  usually  be  necessary 
to  maintain  the  intubation  for  three  or  four  days. 

The  tube  should  not  be  left  in  situ  any  longer  than  is  absolutely 
necessary,  to  obviate  pressure  necrosis.  While  the  use  of  anti- 
toxin for  the  relief  of  diphtheria  has  made  less  frequent  the  neces- 
sity for  intubation,  it  is  probably  true  that  a  case  requiring  in- 
tubation will  give  obstruction  symptoms  for  three  days,  even 
though  antitoxin  be  given.  This  is  to  be  borne  in  mind  in  ar- 
riving at  a  conclusion  as  to  when  the  tube  may  be  permanently 
removed. 


TRACHEOTOMY 

The  care  of  the  patient  subjected  to  tracheotomy  is  the  same 
whether  the  operation  involves  the  high,  low,  or  intermediate 
method,  and,  indeed,  whether  the  operation  be  done  for  the  pur- 
pose of  relieving  dyspnea  or 
as  a  preliminary  step  to 
surgical  invasion  of  the 
pharynx,  larynx,  etc.  The 
tube  most  generally  em- 
ployed is  the  one  known  as 
the  Luer  tube  (Fig.  258), 
which  is  a  double  one  per- 
mitting of  removal  of  the 
inner  cannula  for  the  pur- 
pose of  cleansing  it.  The 
shield  is  furnished  with  two 
slits  which  permit  of  the  at- 
tachment of  tapes,  by  means 
of  which  the  cannula  is  held 
in  place.  Fig.  259  shows  the  means  of  holding  the  apparatus  in 
place,  and  also  shows  the  position  the  patient  should  be  placed  in 
after  the  operation  is  completed.  Tracheotomy  done  for  relief  of 
obstructive  inflammation  requires  assiduous  attention  to  the  de- 
tails of  after-treatment.  The  number  and  character  of  inspira- 
tory efforts  are  the  guide  as  to  efficiency  of  the  measure  of  relief. 
The  lumen  of  the  cannula  must  be  kept  free  at  all  times,  and  an 
attendant  must  be  constantly  on  watch  in  order  to  correct  any  fal- 
lacy in  this  regard. 


Fig.  258. — Liter's  Double  Tracheal,  Can- 
nula,     (von  Bergmann.) 


OPERATIONS  ON  THE  LARYNX  AND  TRACHEA     381 

When  evidence  of  obstruction  occurs  the  inner  cannula  is  im- 
mediately removed  and  cleansed  by  means  of  wet  sterile  gauze, 
pushed  through  it  with  a  bent  probe.  If  the  dyspnea  is  not  re- 
lieved by  this  means,  the  outer  tube  must  be  removed,  cleansed, 
and  reinserted.     The  latter  measure  is  rarely  necessary.     How- 


Fig.   259. — Tracheotomy  Tube   in   Place,   and   Position   of  Patient 
after   Tracheotomy,      (von  Bergmann.) 

ever,  it  does  at  times  occur  that  dried  secretions  accumulate  over 
the  end  of  the  outer  tube,  and  these  must  be  removed  to  free  the 
cannula. 

One  of  the  causes  of  unfavorable  outcome  following  trache- 
otomy is  due  to  the  absence  of  the  normal  amount  of  moisture 
contributed  to  the  inspired  air  in  its  passage  over  the  mucosa  of 
nose,  mouth,  and  pharynx.  Moist  air  is  an  important  means  of 
preventing  the  drying  of  secretions  in  the  cannula.  For  the  pur- 
pose, the  bed  is  covered  with  a  hood  and  the  bedclothes  covered 
with  waterproof  material.  A  croup  kettle  is  located  near  the 
bed  with  the  nozzle  led  beneath  the  hood.  Various  medicinal 
agents  have  been  added  to  the  water,  which  become  vaporized 
when  the  mixture  boils  and  are  supposed  to  contribute  to  the 
beneficial  effect  of  the  moist  air.  It  is  probable  that  the  latter 
is  the  important  consideration,  though  there  is  no  objection  to 


382  OPERATIONS   ON  THE   NECK 

the  addition  of  medicinal  agents,  provided  that  some  non-irritat- 
ing substance  be  used. 

If  obstruction  occur  after  the  inner  tube  has  been  removed,  a 
soft  catheter  may  be  introduced  through  the  inner  tube  and  suc- 
tion made  with  a  syringe.  This  measure  should  not  be  employed 
as  a  routine,  but  only  in  the  event  of  the  failure  of  the  removal 
of  the  inner  tube  to  relieve  the  obstruction. 

The  entire  apparatus  should  not  be  removed  if  avoidable  for 
three  days  following  its  introduction,  i.e.,  until  a  distinct  tract 
has  been  formed  in  the  wound.  Reintroduction  at  an  earlier 
period  may  be  attended  with  unsurmountable  difficulties.  In  any 
event,  the  patient  must  be  postured  in  the  same  way  as  for  trache- 
otomy, and  the  edges  of  the  tracheal  wound  held  open  with  hooks. 
If,  for  the  reasons  stated,  the  tube  must  be  removed  before  a  tract 
has  been  formed,  the  same  precautions  must  be  taken. 

When  changing  the  tracheotomy  tube  no  time  must  be  lost 
before  the  second  one  is  introduced,  as  the  tracheal  wound  con- 
tracts very  rapidly.  For  the  purpose  it  is  wise  to  introduce  into 
the  wound  at  once  a  suitably  sized  rubber  catheter  and  slip  the 
new  tube  into  place  over  it.  Ultimate  decannulement  should  be 
performed  when  the  air  passes  freely  through  the  larynx.  The 
average  period  when  this  can  be  done  in  cases  of  diphtheria  is 
from  the  sixth  to  the  tenth  day.  When  the  tracheotomy  has  been 
done  as  accessory  to  operations  involving 
the  upper  air  passages,  a  shorter  period  of 
time  may  be  allowed  to  elapse. 

Cannulas  which  have  openings  in  them 
are  best  used  for  this  reason.  This  per- 
mits of  removal  of  the  inner  tube  and  its 
replacement  with  an  inner  tube  furnished 
with  an  obturator.  Fig.  260  shows  a  tube 
which  has  been  used  by  v.  Brans  for  years. 

Fig.  260. — Cannula   Used  j  j 

for  Convalescents     The  inner  tube  is  not  pervious  and  reaches 
after    Tracheotomy,     c^e^at  beyond  the  outer  one.     This  al- 

{von  Bergmann.) 

lows  the  air  to  pass  without  difficulty,  and 
should  the  patient  develop  obstruction,  it  can  readily  be  removed 
and  the  pervious  inner  tube  substituted.  If  the  patient  sleeps 
quietly  for  two  nights  with  the  impervious  tube  in  situ,  the  per- 
manent decannulement  may  be  made. 


OPERATIONS  ON  THE  LARYNX  AND  TRACHEA     383 

When  the  tube  is  permanently  removed,  the  wound  usually 
closes  in  a  few  days.  While  the  tube  is  in  situ  the  skin  contigu- 
ous to  the  wound  should  be  kept  covered  with  5  per  cent,  sterile 
iodoform  in  vaselin  to  prevent  excoriation  and  eczema,  due  to  the 
presence  of  secretions. 

Following  tracheotomy  for  removal  of  foreign  body,  the 
elaborate  after-treatment  is  regarded  as  unnecessary.  In  some 
cases  the  tube  is  not  introduced  and  the  tracheal  wound  closed 
with  suture  and  the  superficial  wound  drained.  However,  it  is 
recommended  that  if  the  tube  be  used,  provision  for  moistening 
the  inspired  air  be  made.  It  is  a  small  matter,  and  may  obviate 
disagreeable  if  not  dangerous  complications.  The  use  of  a  gauze 
apron  moistened  with  water  and  placed  over  the  tracheotomy  tube 
opening  is  a  procrastination,  as  it  cannot  fill  the  purpose.  Em- 
physema of  the  soft  parts  of  the  neck  occurs  when  the  tube  is 
dislodged  from  the  trachea  by  coughing  or  as  the  result  of  un- 
skillful manipulations  on  part  of  the  attendant.  The  condition 
itself  is  not  serious,  but  may  necessitate  the  secondary  introduc- 
tion of  a  longer  tube  which  reaches  beyond  the  tissues  swollen  by 
the  presence  of  air.  This,  of  course,  is  likely  to  occur  only  be- 
fore a  canal  has  been  formed  by  the  tube,  and  argues  for  not 
changing  the  tube  for  the  first  few  days  following  the  operation. 

Pressure  necrosis  from  the  tube  is  a  common  complication. 
A  properly  fitting  tube  tends  to  prevent  this  complication.  When 
ulceration  occurs  the  mucus  expelled  from  the  tube  is  streaked 
with  blood.  This  should  be  regarded  as  evidence  that  the  tube  is 
not  appropriate  for  the  case,  and  a  proper  one  should  be  speedily 
substituted. 

After  permanent  decannulement  the  care  of  the  wound  is  a 
simple  matter.  The  dressing  is  changed  every  other  day  until 
healing  takes  place.  At  times  a  sinus  leading  to  a  necrosed  area 
of  tracheal  cartilage  persists  for  a  considerable  period  of  time, 
but  this  usually  heals  without  interference.  The  healing  may  be 
hastened  by  painting  the  sinus  wall  with  tincture  of  iodin  every 
second  day  for  several  sittings. 

LARYNGECTOMY 

The  high  mortality  rate  following  laryngectomy  has  been  due 
to  infection,  the  result  of  the  invasion  of  the  stump  of  the  trachea 


384 


OPERATIONS    OX   THE    NECK 


by  saliva  and  mucous  secretions  from  the  mouth  and  pharynx, 
which  are,  of  course,  more  or  less  infected  with  bacteria.  The  in- 
fection extends  to  the  lung,  and  a  so-called  deglutition  or  aspira- 
tion broncho-pneumonia  carries  off  the  patient.  While  the  modi- 
fication of  technic  recently  employed,  which  involves  isolation 
of  the  respiratory  tract  by  fastening  the  stump  of  the  trachea  to 
the  skin,  has  quite  eliminated  this  element  of  danger,  septic  cellu- 
litis in  the  deep  tissues  of  the  neck,  with  extension  to  the  medi- 
astinal and  pleural  cavities,  still  remains  as  a  menacing  compli- 
cation during  the  postoperative  period. 

When  the  tracheal  stump  is  fastened  to  the  skin  by  suture  and 
furnished  with  a  suitable  cannula  (Fig.  261)  the  care  of  the  pa- 
tient is  in  all  respects 
similar  to  that  de- 
scribed under  trache- 
otomy, as  far  as  modi- 
fication of  the  inspired 
air  is  concerned  (page 
381  et  seq.)  As  far 
as  the  infective  com- 
plications  are  con- 
cerned, Bryant  sug- 
gests that  the  patient 
be   taught   to   swallow 


while  in  the  Trendel- 
enburg position  before 
the  operation  is  begun. 
Patients  afflicted  with 
disease  calling  for  so 
radical  a  measure  as 
complete  laryngec- 


Fig.  261. — Perier  Cannula  Used  after  Laryn- 
gectomy,    {von  Bergmann.) 


tomy  will  be  found 
willing  to  undergo  the  discomfort  incumbent  upon  this  training. 
During  this  time  the  mouth  and  pharynx  are  frequently  cleansed, 
as  already  described  (page  362). 

The  wound  is  usually  only  partially  closed  when  the  extent  of 
the  disease  has  necessitated  removal  of  the  epiglottis  and  the  mu- 
cosa, rendering  suture  of  the  tracheal  stump  to  the  latter  mem- 
brane impracticable.     In  the  former  class  of  cases  the  danger  of 


OPERATIONS  ON  THE  LARYNX  AND  TRACHEA     385 

infection  is  obviously  greater  than  obtains  in  the  latter.  Imme- 
diatedly  after  the  operation  the  wound  is  packed  with  gauze,  the 
patient  is  placed  in  a  position  with  the  head  dependent,  to  facili- 
tate drainage,  and  the  attendant  frequently  cleanses  the  mouth  in 
the  manner  described  under  operations  in  the  latter  situation. 

Rectal  feeding  every  sixth  hour  and  saline  enema  every  third 
hour  are  employed.  The  gauze  packing  is  changed  twice  or  three 
times  daily.  This  latter  step  causes  much  discomfort  if  clumsily 
executed,  and  the  anticipation  of  the  impending  distress  has  an 
exceedingly  depressing  influence  upon  the  patient's  general  con- 
dition. The  suggestions  already  stated  with  regard  to  light  pack- 
ing and  gentle  removal  of  the  gauze  should  be  adopted.  It  is  not 
amiss  to  soak  the  gauze  in  sterile  potassium  permanganate  and 
change  the  packing  before  the  moisture  is  sufficiently  absorbed  to 
permit  of  agglutination  to  the  surfaces  of  the  wound.  If,  because 
of  excessive  secretion,  lavage  of  the  wound  surfaces  is  indicated, 
the  patient's  head  is  still  farther  lowered  and  the  cleansing  is  made 
by  introducing  gently  into  the  lower  portion  of  the  wound  a  sterile 
soft  catheter  connected  with  a  syringe.  The  apparatus  shown  in 
Fig.  251  will  be  found  serviceable  for  the  purpose.  The  patient 
holds  the  mouth  over  a  basin  and  the  fluid  enters  from  below  and 
runs  out  above  between  the  lips.  If  vomiting  has  occurred  im- 
mediately following  the  operation,  the  gauze  should  be  removed 
as  soon  as  the  vomiting  ceases  and  lavage  made  in  the  manner 
indicated.  "When  gastric  alimentation  is  begun,  sterile  food  is 
administered  by  means  of  a  sterile  catheter  passed  into  the 
esophagus. 

Following  the  third  day  after  the  operation  the  patient  should 
attempt  to  swallow  small  quan- 
tities of  sterile  water.  Moderate 
pressure  with  the  fingers  against 
the  outer  surface  of  the  neck  will 
facilitate  the  effort,  and,  indeed, 
the  training  the  patient  has  had 
in  swallowing  wdiile  in  the  Tren- 
delenburg  posture  will  be  found 
to  have  been  of  value. 

As  regards  the  wearing  of  an       „      ...     „        .       ,    . 

Fig.  262. — Gussenbaiier  s  Artificial 

artificial  larynx,  suturing  in  situ  Larynx.    (Bryant.) 


386 


OPERATIONS   ON  THE   NECK 


of  the  trachea  to  the  mucosa  of  the  epiglottis,  of  course,  does  not 
call  for  any  apparatus,  phonation  being  accomplished  with  the 
tongue  and  lips.  When  the  stump  of  the  trachea  is  not  fastened  to 
the  skin,  Gussenbauer  s  artificial  larynx  (Fig.  262)  will  he  found 
serviceable.  This  apparatus  may  form  the  basis  of  one  which, 
no  doubt,  will  need  some  modification  in  construction  to  suit  the 


Fig.  263. — Gluck's  Phonation  Apparatus   in  Place.     1,  Cup  with  Valve;  2,  Voice. 

{von  Bergmann.) 

individual  case.  When  the  stump  of  the  trachea  has  been  fastened 
to  the  skin,  a  measure  now  quite  universally  employed,  the  ap- 
paratus of  Gliick  (Fig.  263)  has  given  satisfactory  results.  The 
illustration  explains  itself.  It  may,  however,  be  stated  that  only 
a  limited  number  of  patients  find  the  use  of  an  artificial  speaking- 
apparatus  of  service.     It  is  probable  that  an  apparatus  such  as 


OPERATIONS  ON  THE  LARYNX  AND  TRACHEA     387 

Gluck's  will  be  found  the  least  objectionable.  The  other  forms 
of  apparatus  expose  the  patient  to  the  entrances  of  pharyngeal 
secretions  into  the  air  passage,  a  danger  from  which  a  valvular 
attachment  to  the  upper  segment  of  the  tube  does  not  give  security. 
No  effort  should  be  made  to  introduce  an  apparatus  until  the  wound 
is  quite  healed,  which  requires  between  five  and  six  weeks. 

The  posture  maintained  by  the  patient  with  the  head  lowered 
should  be  insisted  upon  for  at  least  five  days  following  the  opera- 
tion. During  the  healing  process  the  gauze  packing  will  be  found 
to  be  slowly  dislodged  by  the  granulation  tissue,  and  ultimately 
only  a  small  drain  need  be  inserted  into  the  lower  portion  of  the 
wound.  This  latter  may  be  discontinued  as  soon  as  it  is  evident 
that  the  deep  wound  is  healed.  Unnecessary  prolongation  of  the 
packing  will  cause  the  maintenance  of  a  fistula,  which  may  not 
close  for  months. 

Patients  should  be  guarded  against  the  entrance  of  dust  into 
the  trachea  when  convalescence  has  been  established.  The  wear- 
ing of  a  gauze  apron,  held  in  place  by  tapes,  will  be  found  service- 
able for  the  purpose. 

THYROIDECTOMY 

After  either  partial  or  complete  thyroidectomy  the  persistent 
oozing  of  blood  usually  requires  tamponade  of  the  wound  for  two 
or  three  days  following  the  operation.  This  is,  of  course,  not 
necessary  in  all  cases,  and,  indeed,  the  wound  may  in  some  in- 
stances be  closed  and  dependent  drainage  made,  which  may  be 
removed  in  two  days,  if  no  evidence  of  infection  develops.  When 
tamponade  has  been  made  the  pressure  upon  the  recurrent  laryn- 
geal nerve,  the  phrenic,  the  pneumogastric  nerves,  and  the  trachea 
must  be  considered  in  connection  with  symptoms,  the  result  of  the 
presence  of  the  gauze.  It  is  never  necessary  to  make  sufficient 
pressure  to  produce  modification  of  respiration  from  pressure  on 
the  trachea,  but  heart  symptoms  and  aphonia  or  hoarseness  may 
be  produced,  which  might  be  regarded  as  the  result  of  injury  to 
nerve  fibers,  which,  as  a  matter  of  fact,  soon  clear  up  when  the 
tamponade  is  removed.  Tamponade  for  the  purpose  of  arresting 
bleeding  need  not  be  left  in  situ  longer  than  forty-eight  hours,  and 
the  tampon  (preferably,  for  the  purpose,  the  Mickulicz  tampon 
should  be  used)  may  then  be  removed. 
27 


388  OPERATIONS    ON   THE    NECK 

At  times  a  hematoma  forms  if  the  packing  has  been  omitted, 
which  gives  rise  to  pressure  symptoms,  though  these  disappear 
when  the  blood  clots  are  expressed  or  dislodged  with  a  saline  irriga- 
tion or  the  same  solution  introduced  through  the  drainage  opening 
by  means  of  a  syringe.  At  times  a  kinking  of  the  atrophied 
trachea,  which  latter  condition  is  the  result  of  prolonged  pressure 
on  the  trachea,  causes  severe  dyspnea.  This  is  corrected  by  ex- 
tending forcibly  the  head  and  maintaining  it  persistently  in  that 
position. 

Dyspnea  following  thyroidectomy  has  been  caused  by  the  ac- 
cumulation of  saliva  in  the  upper  segment  of  the  pharynx  due  to 
paralysis  of  the  esophagus.  However,  this  condition  of  affairs 
is  exceedingly  rare  and  may  be  obviated  by  lowering  the  head  of 
the  bed,  allowing  thus  of  discharge  of  the  saliva  and  its  expulsion 
from  the  mouth  either  by  gravity  or  as  the  result  of  voluntary 
ex23ectoration. 

The  rise  of  temperature  following  removal  of  the  thyroid  gland 
is  not  necessarily  ascribable  to  infection  nor,  indeed,  to  absorp- 
tion of  ferments.  In  almost  all  cases  of  thyroidectomy  a  sharp 
pyrexia  follows  the  operation.  This  disturbance  of  metabolism 
has  been  attributed  to  absorption  of  portions  of  glandular  elements 
coming  in  contact  with  a  large  surface  of  tissue  subjected  to  trauma, 
and  is  clinically  differentiated  from  the  rise  of  temperature  due 
to  infection,  inasmuch  as  the  latter  (infection)  is  accompanied  by 
the  concomitant  symptoms  due  to  the  infection,  such  as  increase  of 
pulse  rate  and  the  local  symptoms  of  inflammation,  pain,  etc., 
while  the  pyrexia  due  to  absorption  of  glandular  elements  is  a  soli- 
tary symptom  not  accompanied  by  the  clinical  picture,  the  out- 
come of  the  invasion  of  bacteria. 

Pneumonia  occurs  as  a  part  of  sepsis,  but  is  also  due  to  paralysis 
of  the  larynx  due  to  injury  or  pressure  on  the  recurrent  laryngeal 
nerve.  In  the  latter  instance,  the  pneumonia  may  be  regarded  as 
an  aspiration  pneumonia  and  belongs  to  the  class  of  lung  inflam- 
mations following  tracheotomy.  Hoarseness  or  aphonia  following 
thyroidectomy  is  an  indication  for  employment  of  the  precautions 
with  regard  to  the  inspiration  of  moist  air,  described  under  the 
head  of  tracheotomy  (page  381),  and  removal  of  packing  or  the 
blood  clots  of  a  hematoma  at  as  early  a  period  as  is  consistent  with 
the  other  symptoms.     If  infection  of  the  wound  occurs,  the  care 


OPERATIONS   ON  THE   LARYNX  AND  TRACHEA  389 

and  treatment  of  the  wound  is  in  all  respects  similar  to  that  which 
obtains  in  other  situations  of  the  body.  It  is  well  to  reiterate  iu 
this  connection  that  early  drainage  of  the  infected  area  is  especially 
indicated  here  because  of  the  danger  of  rapid  invasion  of  the 
mediastinum  and  pleural  cavities  (page  376). 

Tetany  and  chronic  myxedema  have  been  considered  as  two  dis- 
tinct afflictions  following  thyroidectomy  and  due  to  removal  of  the 
gland.  At  this  time  they  are  regarded  as  degrees  of  the  same 
condition. 

Acute  myxedema  is  now  quite  rare,  as  experience  has  taught 
that  it  may  be  prevented  by  leaving  behind  a  portion  of  the  gland 
or  an  accessory  gland.  The  symptoms  of  this  condition  appear 
either  immediately  after  the  operation  or  may  develop  several  days 
later  (up  to  the  tenth  day).  Prodromal  symptoms,  such  as  re- 
stricted motion  or  rigidity  of  the  muscles  of  the  extremities,  occur. 
Clivostelc's  sign — that  of  a  fulminating  contraction  of  the  face 
following  a  tap  over  the  facial  nerve — or  Trousseau  s  sign — that 
of  a  spasmodic  contracture  of  the  muscles  of  an  extremity  follow- 
ing pressure  upon  one  of  the  main  arteries  or  nerves  supplying 
the  limb — together  with  the  occurrence  of  the  stiffness  of  the 
muscles  mentioned,  may  make  the  diagnosis  easy. 

As  the  affliction  develops,  the  entire  body  becomes  progressively 
tetanic.  There  is  little,  if  any,  disturbance  of  temperature  during 
the  attacks  and  the  sensorium  remains  clear.  The  prognosis  of 
this  condition  is  exceedingly  unfavorable.  It  is  worthy  of  note 
that  the  intensity  of  the  postoperative  manifestations  in  this  re- 
gard bears  a  direct  proportion  to  the  amount  of  gland  tissue  left 
in  situ. 

Chronic  Postoperative  Myxedema  is  manifested  by  diminished 
mental  activity  and  edematous  swelling  of  the  skin.  For  com- 
plete description  of  the  symptomatology,  the  reader  is  referred 
to  works  on  the  principles  of  surgery.  In  this  connection  it  is 
proper  to  state  that  the  clinical  picture  is  the  result  of  the  ab- 
sence or  destruction  of  normal  thyroid  tissue,  a  deviation  from 
the  original  intent  of  this  work  justified  by  the  fact  that  it  is 
this  which  presents  the  most  important  indication  for  postopera- 
tive treatment. 

Treatment  of  Tetany  and  Cachexia  after  Thyroidectomy.— As 
already  stated,  the  fact  that,  as  a  rule,  the  symptoms  mentioned 


390  OPERATIONS    ON   THE    NECK 

do  not  occur  when  a  portion  of  the  gland  is  left  behind  points  the 
way  with  respect  to  treatment.  It  must  be  borne  in  mind  that 
the  residual  amount  of  glandular  tissue  may  not  suffice  to  fur- 
nish the  necessary  elements  to  the  processes  of  metabolism,  and, 
again,  the  character  of  the  diseased  process  for  which  thyroid- 
ectomy is  undertaken  may  preclude  leaving  any  of  its  tissue  be- 
hind, and,  again,  it  is  not  impossible  that  the  changes  in  the 
gland  may  be  such  that  the  portion  left  behind  does  not  func- 
tionate sufficiently  for  the  purpose. 

It  may  be  stated  that  the  introduction  of  thyroid  tissue  into 
the  system  obviates  the  occurrence  of  unfavorable  manifestations. 
The  injection  method,  while  effective,  should  only  be  employed 
when  the  prodromic  symptoms  of  tetany  described  above  are 
elicited,  and  the  introduction  by  mouth  of  desiccated  thyroid 
extract,  now  obtainable  in  the  market,  should  be  used  in  all  cases 
whether  symptoms  arise  or  not.  To  summarize,  inject  extract  of 
thyroid  if  the  entire  gland  has  been  removed  and  there  be  the 
slightest  indications  of  tetany.  Give  desiccated  extract  of  thyroid 
in  all  cases.  When  the  acute  symptoms  of  myxedematous  tetany 
subside,  discontinue  the  injections  and  give  the  preparation  by 
the  mouth.  In  all  cases  begin  treatment  as  soon  after  the  opera- 
tion as  possible,  and  maintain  it  for  a  long  period  of  time. 

If,  by  reason  of  the  urgency  of  the  indications,  thyroid  ex- 
tract is  introduced  by  injection,  a  long  needle  and  roomy  syringe 
barrel   should  be  used.      The   illustration   shows   an  instrument 

which  is  serviceable  for 
the  purpose  (Fig.  264). 
The  injection  is  prefer- 

Fig.  264.— Record  Syringe,  Barrel  of  Ground  ably  made  into  the  glll- 

Glass     with     Metal     Plunger      and     Long  teal    muscle         The    thv- 
Needle;   Useful    for    Deep    Muscular    In-  . 

jectioxs.  r01d    extract    is    mixed 

with  sterile  water, 
using  about  five  grains  of  the  desiccated  extract  in  a  half  dram 
of  water;  this  is  sucked  up  into  the  barrel,  and  the  needle  is  in- 
troduced into  the  buttock  before  the  connection  is  made.  The 
protruding  portion  is  watched  for  hemorrhage,  the  absence  of 
which  indicates  that  a  vein  has  not  been  entered.  The  barrel  is 
now  connected  to  the  needle,  and  the  injection  slowly  made.  The 
skin  should  be  first  wiped  off  with  denatured  alcohol.     Local  re- 


OPERATIONS  ON  THE  LARYNX  AND  TRACHEA     391 

action  does  not  occur  if  these  instructions  are  followed.  The  in- 
jection may  be  repeated  at  six-hour  intervals  until  the  patient  is 
in  condition  to  take  the  preparation  by  mouth.  Tablets  of  five 
grains  each  are  taken  after  meals.  The  dosage  varies  with  the  in- 
dications, being  increased,  if  necessary,  to  fifteen  grains  three 
times  daily.  This  dose  may  give  rise  to  cardiac  disturbances 
(tachycardia),  demanding  reduction  in  the  size  of  the  dose.  The 
treatment  must  be  carried  on  for  years  unless  a  regeneration  of 
the  portion  of  gland  left  behind  becomes  commensurate  with  the 
demands  of  metabolism.  Interruption  of  the  treatment  is  invari- 
ably attended  with  return  of  symptoms,  which  promptly  disap- 
pear upon  renewal  of  the  administration,  unless  the  conditions 
just  mentioned  obtain. 

It  is  generally  regarded  wise  to  limit  the  amount  of  meat 
taken  by  the  patient.  This  should  involve  no  special  hardship, 
and  while  its  rationale  is  not  clearly  apparent,  the  precaution  is 
advised  on  general  principles. 

EXOTHYROPEXY 

Exothyropexy  {Jaubolay,  Poncet,  Berard)  is  not  generally 
employed.  It  consists  of  delivering  the  thyroid  out  of  the  super- 
ficial wound  and  permitting  it  to  strangulate.  The  after-treat- 
ment does  not  differ  from  that  of  thyroidectomy  except  that  the 
temperature  symptoms  are  more  marked,  and  that,  for  obvious 
reasons,  infection  is  more  liable  to  obtain.  The  exposed  goiter 
must  be  dressed  every  day.  The  first  few  days  after  the  opera- 
tion the  gland  discharges  copious  amounts  of  clear  fluid  (goiter 
sweats).  This  necessitates  more  frequent  changing  of  dressings. 
The  method  is  not  regarded  as  a  desirable  one. 

DRAINAGE  AND   PACKING   OF   CYSTS  OF  THE  THYROID 

Drainage  and  packing  of  cysts  of  the  thyroid  are  practiced 
when  the  neoplasm  makes  pressure.  The  measure  is  used  upon 
elderly  persons  in  whom  the  radical  excision  is  contraindicated. 

Simple  drainage  does  not  often  achieve  obliteration  of  the 
sac.  The  drainage  material  is  left  in  situ  until  forced  out  by  the 
proliferating  scar  tissue. 

Packing  more  frequently  achieves  the  purpose.     The  packing 


392  OPERATIONS    OX   THE   NECK 

is  changed  every  second  day.  Care  must  be  taken  to  obviate  the 
occurrence  of  infection.  The  cavity  may  be  syringed  out  with  a 
mild  solution  of  iodin,  a  few  drops  to  the  pint  of  water,  with 
the  view  of  stimulating  repair  and  preventing  infection.  At 
longer  intervals  the  cavity  may  be  painted  with  the  pure  tincture 
of  iodin,  though  this  had  best  be  done  after  considerable  con- 
traction of  the  cyst  cavity  has  taken  place.  The  injection  of 
hydrogen  peroxid  is  permissible,  with  the  view  of  facilitating  re- 
moval of  the  gauze  tamponade,  as  the  cyst  does  not  communicate 
with  the  deep  fascial  spaces  of  the  neck.  If  the  cyst  extends  to  be- 
hind the  sternum,  care  should  be  exercised  with  respect  to  the  ac- 
cumulation of  cleansing  fluids  in  its  dependent  portion,  as  forc- 
ible tamponade  may  rupture  the  cyst  wall  and  distribute  the 
contents  into  the  mediastinum.  Especially  should  this  be  guarded 
against  if  suppuration  occurs.  In  the  latter  instance  the  cyst 
should  be  emptied  by  suction  with  a  syringe  connected  to  a  soft 
rubber  catheter,  which  is  introduced  through  the  wound.  There- 
after gauze  wick  drainage  should  be  introduced  well  to  the  bottom 
of  the  poststernal  cavity,  and  the  end  of  the  drain  should  be  per- 
mitted to  escape  beside  the  tamponade  occupying  the  rest  of  the 
cavity.  Entire  obliteration  may  ultimately  be  obtained  in  this 
way.  When  total  excision  of  thyroid  cysts  has  been  accomplished 
the  after-treatment  does  not  differ  in  any  essential  regard  from 
that  described  under  thyroidectomy. 

ESOPHAGOTOMY 

Cervical  esophagotomy  does  not  call  for  special  local  prepara- 
tion. The  fact  that  the  manipulations  are  carried  on  contiguous  to 
the  apparatus  employed  for  narcosis  suggests  that  provision  should 
be  made  for  sterile  narcosis  (page  311).  The  administration  of 
sterile  diet,  while  indicated,  is  probably  not  applicable,  as  the 
operation  is  usually  undertaken  to  overcome  obstruction,  a  con- 
dition which,  of  course,  precludes  the  introduction  of  food. 
Rectal  alimentation  should  be  maintained  until  just  before  nar- 
cosis is  begun.  The  last  enema  may  contain  stimulants  which 
are  designed  to  combat  shock.  The  usual  preparations  for  the 
hypodermic  administration  of  stimulants  should  be  made,  espe- 
cially as  the  exhaustion  due  to  lack  of  proper  nourishment  pre- 
disposes to  collapse.     Thirst  is  a  marked  symptom  of  esophageal 


OPERATIONS  ON  THE  LARYNX  AND  TRACHEA     393 

obstruction.  A  high  saline  enema  given  soon  after  the  operation 
will  tend  to  overcome  this  distressing  manifestation.  Introduc- 
tion of  food  with  the  stomach  tube  may  be  begun  forty-eight  hours 
after  the  operation,  though  care  must  be  taken  to  sterilize  the 
tube  and  to  introduce  it  with  gentleness,  especially  if  an  effort 
has  been  made  to  obtain  primary  union  in  the  esophageal  wound. 
The  introduction  of  food  into  the  stomach  should  not  be  begun 
until  a  reasonable  certainty  exists  that  the  postoperative  vomiting 
has  ceased.  It  is  obvious  that  soiling  of  the  wound  surfaces  with 
the  contents  of  the  stomach  is  objectionable. 

The  care  of  the  wound  after  esophagotomy  varies  slightly  with 
regard  to  whether  the  esophageal  wound  has  been  closed  by  su- 
ture or  not.  It  is  probable  that  complete  closure  of  the  wound  is 
unwise.  Contamination  during  the  operation  may  be  avoided, 
but,  as  already  stated,  the  vomited  matter  which  is  almost  invari- 
ably discharged  after  an  operation  is  likely  to  infect  the  wound. 
In  some  instances  the  wound  in  the  esophagus  is  closed  and  the 
wound  in  the  neck  freely  drained.  In  either  case  cleansing  of 
the  wound  should  be  practiced  at  the  end  of  the  postoperative 
vomiting,  with  the  view  of  lessening  the  chances  of  infection. 

If  the  esophageal  wound  has  been  left  open  this  step  would 
seem  very  necessary,  which,  indeed,  is  the  case.  However,  on 
the  other  hand,  the  fact  that  the  wound  is  open  will  permit  of 
more  satisfactory  cleansing,  and  the  attendant  has  more  assur- 
ance that  infective  material  is  not  so  likely  to  burrow  in  the  deep 
fascial  spaces.  It  is  a  good  rule  in  surgery  to  provide  for  free 
access  to  surfaces  which  are  liable  to  infection  or  are  to  be  sub- 
jected to  manipulations.  If  the  esophageal  wound  has  been 
closed,  the  presence  of  minute  portions  of  material  which  may 
have  leaked  into  the  surrounding  tissues  may  escape  notice  and  a 
fallacious  complacency  be  engendered  which  may  lead  to  unfa- 
vorable results.  It  is  also  well  to  bear  in  mind  that  saliva  is  more 
or  less  continuously  passed  down  the  esophagus,  and  this  con- 
stitutes an  element  of  danger  in  the  respect  mentioned.  In  order 
to  lessen  the  infective  character  of  the  saliva,  frequent  liberal 
lavage  of  the  mouth  with  boric  acid  or  similar  solution  should 
be  made.  The  patient  will  regard  the  latter  measure  as  a  very 
satisfying  one,  as  thirst,  if  not  relieved  by  it,  is  less  distressing 
because  of  it. 


394  OPERATIONS    ON  THE   NECK 

The  initial  dressing  should  not  remain  in  situ  more  than 
twenty-four  hours,  even  though  vomiting  does  not  occur,  and, 
indeed,  cleansing  of  the  wound  should  be  done  twice  daily  for  four 
days  after  the  operation,  reeding  with  liquid  food  may  be  car- 
ried out  at  each  dressing,  and  all  foreign  matter  removed  from 
the  wound  immediately  thereafter.  The  liquid  food  should  be 
sterile  (page  430),  for  obvious  reasons. 

The  wound  in  the  esophagus  heals  usually  in  ten  days.  The 
administration  of  solid  food  should  not  be  begun  until  there  be 
reasonable  assurance  that  the  esophageal  wound  is  closed. 


CHAPTER    XIX 

OPERATIONS   ON   THE  THORAX 

Excision   of   the   Breast — Thoracotomy — Thoracoplasty — Decortication    of   the 
Lung — Resection  of  Large  Surfaces  of  the  Thoracic  Wall — The  Deformity. 

EXCISION   OF   THE   BREAST 

The  special  local  preparation  for  excision  of  the  breast  relates 
to  shaving  the  axilla  and  thoroughly  cleansing  of  the  skin  of  the 
thorax,  neck  and  arm  of  the  patient- 
Excision  of  the  breast  for  malignant  disease  contemplates  re- 
moval of  tissues,  including  the  lymphatics  concerned  in  draining 
the  mammary  gland,  a  procedure  involving  invasion  of  large 
areas  of  tissue,  a  factor  which  calls  for  especial  care  in  the  ob- 
servance of  antiseptic  precautions  before,  during,  and  after  the 
operative  procedure.  As  hemorrhage  is  likely  to  be  severe  dur- 
ing the  operation,  a  liberal  number  of  gauze  sponges  and  a  large 
number  of  towels  should  be  available. 

When  the  excision  is  followed  by  complete  closure  of  the 
wound  the  local  after-treatment  does  not  differ  from  that  em- 
ployed elsewhere,  except  that  retention  sutures  (page  215),  Figs. 
179  to  184)  are  frequently  introduced. 

Drainage  from  the  dependent  portion  of  the  wound,  which 
corresponds  to  the  lower  part  of  the  axillary  flap,  is  also  intro- 
duced in  the  majority  of  cases,  the  withdrawal  of  which  is  gov- 
erned by  the  same  rules  applied  elsewhere  (page  186).  In  this 
situation  the  oozing  of  blood  may  obstruct  the  drainage  tube,  and 
while  the  dressing  should  not  be  unnecessarily  disturbed,  it  should 
be  changed  at  the  end  of  twenty-four  hours  if  there  has  been  much 
oozing  immediately  subsequent  to  the  operation,  with  the  view  of 
removing  the  tube  and  reestablishing  its  patency  when  it  may  be 
again  introduced,  or  better  still  a  fresh  tube  may  be  inserted  in 
its  place.     The  wound  may  then  be  redressed  and  the  subsequent 

395 


396 


OPERATIONS   ON  THE  THORAX 


changes  of  dressings  be  governed  as  to  frequency  by  the  indica- 
tions, as  already  stated.  After  radical  excision  for  malignant 
disease  of  the  breast,  the  wound  presents  the  appearance  shown 
in  Fig.  265.  The  drainage  tube  is  seen  to  emerge  from  an  in- 
cision made  at  the  dependent  portion  of  the  subcutaneous  wound, 
through  the  latissimus  dorsi  muscle.  The  retention  sutures  held 
by  buttons  are  also  shown.     If,  however,  it  has  been  impossible 


Fig.  265. — Appearance  of  Wound  after  Excision  of  Breast.      (Gerster.) 


to  bring  into  apposition  the  edges  of  the  wound  because  of  the 
involvement  of  large  surface  of  skin,  a  portion  of  the  wound  is 
left  to  heal  by  granulation.  This  calls  for  slightly  different 
measures  in  the  after-treatment. 

It  is  believed  by  some  observers  that  malignant  disease  recurs 
more  frequently  after  operations  when  the  ultimate  repair  is  at- 
tended with  healing  by  granulation  and  suppuration  than  obtains 
if  primary  union  follows  the  operation.  A  discussion  of  the  cell- 
ular activity  consequent  to  the  formation  of  granulation  tissue 
does  not  belong  here.  It  is  mentioned,  however,  to  emphasize  the 
need  of  preventing  infection  in  the  care  of  wounds  which  heal  by 
granulation.  The  surface  not  covered  by  skin  is  lightly  packed 
with  iodoform  gauze,  and  this  is  changed  at  intervals  of  forty- 
eight  hours.     Each  dressing  is  made  under  strict  aseptic  precau- 


EXCISION   OF  THE   BREAST 


397 


tions,  the  field  being  surrounded  with  sterile  towels  and  the  at- 
tendant prepares  the  hands  and  instruments  in  the  usual  manner. 
When  the  granulations  have  reached  the  skin  level,  the  treatment 
of  the  wound  should  not  be  left  to  the  patient,  but  the  precau- 
tionary measures  mentioned  must  be  persisted  in  until  the  wound 
is  entirely  closed.  The  healing  process  will  be  conserved  by 
strapping  the  wound  with  adhesive  plaster,  which  is  affixed  in 
such  a  manner  as  to  draw  the  edges  of  the  raw  surface  together. 
The  adhesive  strips  should  not  cover  the  entire  surface  of  the 
wound,  but  should  leave  sufficient  space  on  either  side  to  permit 
of  drainage. 

The  Dressing. — A  liberal  amount  of  fluffed  gauze  should  be 
placed  next  the  wound  (Fig.  188)  to  absorb  the  discharges, 
which  in  these  cases,  as  already  stated,  is  likely  to  be  consider- 
able in  quantity.  The  method  of  holding  the  protective  dressing 
in  place  varies  at  the  hands  of  the  operator.  The  immobilization 
of  the  arm  contiguous  to  the  operation  conserves  repair  and  re- 
laxes tension.  On 
the  other  hand,  this 
method  of  bandag- 
ing causes  disuse, 
atrophy,  and  par- 
tial, more  or  less 
persistent  ankylosis 
of  the  shoulder 
joint  and  favors 
cicatricial  contrac- 
tion, which  ulti- 
mately limits  the 
amount  of  motion 
in  the  limb. 

For  this  reason 
it  is  best  not  to 
attempt  a  display 
of  the  art  of  band- 


aging, but  to  re- 
tain the  protective 
dressing   with    a 


sort     of     "cui- 


Fig.  266. — Cuirass  to  Hold  Dressings  in  Place  after 
Removal  of  Breast,      (von  Bergmann.) 


398  OPERATIONS   ON  THE  THORAX 

rass,"  which  permits  of  free  motion  of  the  limb.  The  kind  of 
retention  dressing  which  is  of  great  service  in  this  connection 
is  shown  in  Fig.  266.  It  will  be  seen  that  the  retention  appara- 
tus covers  entirely  the  field  of  operation  including  the  subcla- 
vian triangle,  which  latter  is  frequently  invaded  in  operations 
of  this  sort.  It  also  covers  the  insertion  of  the  major  pectoral 
muscle  and  at  the  same  time  allows  of  free  motion  of  the  arm. 
In  addition  to  this,  the  "  demi-waist  "  is  fastened  behind  and 
presents  a  smooth  surface  in  front,  a  factor  which  contributes  to 
its  serviceability  to  a  not  inconsiderable  degree.  This  demi-waist 
is  readily  made  by  a  seamstress  or  an  adroit  nurse,  and  is  con- 
structed of  unbleached  muslin.  It  is  best  furnished  with  tapes 
set  closely  together,  which  are  attached  behind  and  permit  of 
some  elasticity  with  regard  to  adjustment.  Safety  pins  are  apt 
to  exert  uncomfortable  pressure  when  the  patient  is  in  the  supine 
position. 

During  the  postoperative  period  it  is  well  to  encourage  the 
patient  to  use  the  arm  as  much  as  is  consistent  with  comfort, 
though  no  such  effort  before  the  sixth  day  should  be  encouraged. 
After  this  time  passive  motion  while  the  wound  is  exposed  should 
be  made,  and  later,  at  the  beginning  of  the  tenth  or  twelfth  day, 
the  patient  should  begin  making  muscular  efforts. 

If  the  postoperative  course  is  uncomplicated,  the  drainage 
may  be  permanently  removed  on  the  fourth  day  after  the  opera- 
tion. The  retention  sutures  should  be  taken  out  on  the  seventh 
day,  and  the  apposition  sutures  removed  on  the  tenth  day.  If 
infection  has  occurred,  the  retention  sutures  are  left  in  situ  and 
the  apposition  sutures  removed  as  the  indications  arise,  remov- 
ing those  which  interfere  with  thorough  lavage  and  cleansing  of 
the  wound.  The  retention  suture  may  remain  in  place  for  four- 
teen days  when  infection  has  occurred,  with  the  view  of  obviat- 
ing gaping  of  the  wound  surfaces. 

The  treatment  of  an  infected  case  does  not  vary  from  that  of 
those  cases  which  did  not  permit  of  complete  closure  of  the  wound 
at  the  time  of  the  operation.  Radicalism  with  regard  to  free  in- 
cision and  dependent  drainage  should  be  observed.  The  attend- 
ant need  hardly  fear  on  the  side  of  the  latter  proposition.  It  is 
to  be  borne  in  mind  that  a  large  surface  of  the  body  has  been  sub- 
jected to  trauma,  and  that  a  considerable  area  of  wound  surface 


THORACOTOMY  399 

is  in  a  condition  to  present  an  avenue  of  absorption  for  the  prod- 
ucts of  infection,  and  that  systemic  invasion  is  exceedingly  liable 
to  occur.  For  this  reason  the  admonitions  just  presented  are 
submitted. 

THORACOTOMY 

The  special  preparation  for  thoracotomy  should  take  cogni- 
zance of  the  fact  that  narcotics  have  a  depressing  influence  upon 
respiration,  and  that  the  oxygenation  of  the  circulating  fluid  is 
already  seriously  embarrassed  because  of  the  condition  for  which 
thoracotomy  is  undertaken.  The  attendant  should  have  a  tank 
of  oxygen  close  at  hand  and  be  prepared  to  make  artificial  respi- 
ration. For  the  latter  purpose  the  Fell-O'Dwyer  apparatus,  as 
modified  by  Fell,  will  be  found  useful.  (Described  on  page  409 
et  seq.)  Embarrassing  complications  may  be  avoided  if  this  ap- 
paratus be  at  hand. 

The  patient  should  be  postured  in  such  a  manner  as  to  allow 
of  free  expansion  of  the  sound  side  of  the  thorax.  The  narcosis 
should  be  limited  to  as  short  a  period  of  time  as  possible,  and  all 
preparation  for  operating  should  be  made,  with  the  view  of  ob- 
viating delay. 

Simple  incision  of  the  intercostal  space  for  drainage  of  the 
pleural  cavities  does  not  permit  of  the  ready  removal  of  fibrinous 
exudates,  nor  does  it  allow  of  prolonged  maintenance  of  drain- 
age, for  the  reason  that  as  the  chest  wall  contracts  an  over-riding 
of  the  ribs  contiguous  to  the  incision  and  closure  of  the  wound  is 
likely  to  occur.  However,  the  measure  is  employed  in  children 
and  feeble  persons,  and  with  care  in  the  after-treatment  the  wound 
may  be  kept  sufficiently  patent  to  achieve  sufficient  relief  to,  per- 
haps, permit  of  more  radical  measures  at  a  later  period. 

After  the  incision  has  been  made,  an  ordinary  large-sized 
metal  tracheotomy  tube  (Fig.  258)  is  introduced  into  the  pleural 
cavity  and  fastened  with  tapes  about  the  chest.  The  tube  may 
be  cut  off  at  its  intrathoracic  end  to  suit  the  purpose.  Care 
should  be  taken  to  see  that  the  plate  guard  of  the  tube  lies  flat 
upon  the  thorax.  A  rubber  tube  may  be  passed  through  the  metal 
one  for  purposes  of  drainage  or  suction.  The  metal  tube  should 
be  removed  only  at  long  intervals  if  at  all,  as  the  ribs  will  en- 
croach upon  the  space  at  once  when  it  is  withdrawn.     The  after- 


400 


OPERATIONS  ON  THE  THORAX 


treatment  following  this  method  of  drainage  is  in  all  respects 
similar  to  that  employed  following  resection  of  a  rib.  Fig.  267 
shows  the  tracheotomy  tube  in  situ  held  by  tapes. 


Fig.  267. — Method  of  Drainage  of  Pleural  Cavity  after  Simple  Thoracotomy. 


Excision*  of  part  of  a  rib  permits  of  more  liberal  drainage 
and  removal  of  fibrinous  exudate.  After  discharge  of  the  con- 
tents   of   the    pleural    cavity,    tnbe    drainage    is   introduced    and 

the  distal  ends  of 
the  wound  closed 
by  suture.  Silk- 
worm gut  sutures 
are  most  commonly 
employed  for  the 
purpose,  for  reasons 
already  indicated 
with  regard  to  in- 
fected wounds. 
When  the  operation 
is  finished,  the  wound  presents  the  appearance  shown  in  Fig. 
268. 

The  dressing  should  consist  of  a  large  quantity  of  antiseptic 
gauze,  preferably  fluffed  (Fig.  188),  as  this  form  of  dressing- 
enhances  absorption  of  the  discharges.  The  dressing  should  be 
changed  every  day  for  several  weeks,  and  may  then  be  changed 


Fig.   268. — Wound   with    Drainage   Tubes    after 
Thoracotomy.     {Bryant.) 


THORACOTOMY 


401 


every  forty-eight  hours.  Care  must  be  exercised  in  manipulat- 
ing the  drainage  tubes,  that  they  do  not  slip  into  the  pleural 
cavity,  and  in  each  instance  the  safety  pin  should  be  affixed,  as 
shown  in  the  illustration,  to  prevent  this  accident  between  dress- 
ings. 

The  after-treatment  of  thoracotomy  for  purulent  pleural  in- 
flammation is  a  long  and  tedious  procedure.  Favorable  outcome 
is  only  to  be  expected  as  the  result  of  patient  application  of  meas- 
ures of  relief.  Drainage  should  be  maintained  until  the  dis- 
charge ceases,  or  at  least  until  only  a  serous  exudate  small 
in  quantity  persists,  which  is  the  result  of  the  presence  of  the 
tube.  Too  early  interruption  of  the  drainage  will  result  in  clo- 
sure of  the  superficial  opening  and  reaccumulation  of  the 
exudate.  When  the  tube  is  removed,  it  is  best  to  place  into 
the  opening  several  strands  of  silk-worm  gut  (Fig.  147),  which 
may  be  gradually  lessened  in  number  until  final  healing  takes 
place. 

Aspiration  with  drainage  following  thoracotomy  promotes  ex- 
pansion of  the  lung  and  obliteration  of  the  empyemic  cavity. 
J.  D.  Bryant  has  devised  an  apparatus  for  this  purpose  which 


Fig.  269. — Bryant's  Aspiration  Apparatus.  A,  Hollow  rubber 
cushion;  B,  Distended  rubber  bag;  C,  Stopcock;  D,  Glass 
observation  tube. 


has  proven  of  singular  service  in  cases  under  the  observation  of 
the  writer.  The  apparatus  (Fig.  269)  is  described  in  the  lan- 
guage of  its  inventor. 


402  OPERATIONS  ON  THE  THORAX 

The  end  of  the  tube  projecting  beneath  the  cushion  (a)  is  passed 
into  the  empyemic  cavity  the  proper  distance,  and  the  cushion  (a) 
is  placed  in  contact  with  the  wall  of  the  thorax  in  such  a  manner  as 


Fig.  270. — Aspiration  of  Pleural  Cavity.     A,  The  glass  observa- 
tion tube,   showing  suction  force  applied  by  syringe.     {Bryant.) 

to  command  equally  the  area  surrounding  the  opening  into  the  pleural 
cavity.  The  nozzle  of  an  ordinary  syringe  is  then  inserted  into  the 
distal  end  of  the  tube    (Fig.   270),  the  liquid  withdrawn,  followed 


Fig.  271. — Aspiration  of  Pleural  Cavity.     A,  Segment  of  glass  tube.     Cavity 
aspirated  and  stop-cock  closed  to  prevent  admission  of  air.     (Bryant.) 


THORACOTOMY 


403 


finally  by  sufficient  exhaustion  of  air  to  cause  the  rubber  cushion  to 
fit  closely  enough  to  the  chest  wall  to  prevent  the  passage  of  air  beneath 
it  into  the  pleural  cavity.  The  stop-cock  is  then  closed  (Fig.  271), 
the  syringe  removed,  and  the  nozzle  of  the  rubber  bag  (Fig.  271),  while 
fully  collapsed,  is  inserted  firmly  into  the  open  end  of  the  tube  (Fig. 
272),  the  stop-cock  reversed,  thus  establishing  aspiration,  which  is 


Fig.  272.- — Aspiration  of  Pleural,  Cavity.  The  Collapsed  Rubber  Bag  At- 
tached and  Stop-cock  Opened.  A,  Glass  observation  tube;  the  apparatus  in 
action.     (Bryant.) 


maintained  so  long  as  the  bag  is  expanding.  The  chest  is  then  dressed 
and  the  apparatus  duly  fastened  into  place  as  indicated  in  Fig.  273. 
The  patient  can  go  about  comfortably  with  the  apparatus  in  action 
without  attracting  special  attention.  When  the  bag  is  nearly  dis- 
tended, the  stop-cock  should  be  closed,  the  bag  cleansed,  again  col- 
lapsed, reapplied  and  the  stop-cock  opened. 

If  brisk  and  forcible  aspiration  by  the  syringe  be  made,  the  tube 
will  collapse  (Fig.  270),  and  often  the  discharge  will  be  tinged  with 
blood,  which  can  be  noted  through  the  glass  segment  of  the  tube. 
Continuous  and  mild  aspiration  is  safer  and  quite  as  effective  as  the 
vigorous,  in  the  vast  majority  of  instances.  Tbe  degree  of  distention 
of  the  bag  should  be  frequently  observed  in  order  that  it  may  be 
removed,  cleansed,  and  reapplied  without  interruption  of  aspiration. 
Adhesive  plaster  applied  to  the  chest  around  the  opening  aids  in  the 
exclusion  of  air.  Absorbent  cotton,  thoroughly  wet  with  boric-acid 
28 


404 


OPERATIONS    ON   THE   THORAX 


solution,  or  rubber  tissue  hinders  the  passage  of  air  beneath  the 
cushion.  It  is  very  important  in  this  connection  to  remember  that 
the  cotton,  or  any  small  movable  body,  may  be  drawn  into  the  chest 
unless  care  be  exercised.  Should  this  happen  it  can  be  removed  quite 
readily  in  most  instances  by  moving  around  in  the  cavity  the  inner 
end  of  the  tube  while  making  suction  on  the  outer  with  the  syringe. 

In  the  cases  to  which  aspiration  has  been  applied  it  acted  effi- 
ciently and  promptly,  and  was  easily  managed  by  the  patient. 

It  seems  to  the  writer  that  practicable  aspiration  offers  the  oppor- 


Fig.  273. — Aspiration  of  Pleural  Cavity.     A,  Glass  observation  tube.     The  dress- 
ing applied;  apparatus  held  in  place  by  safety  pins  while  in  action.     (Bryant.) 

tunity  of  prompter  cure  in  excision  cases,  and  not  impossibly  may 
render  needless  the  more  serious  methods  of  practice  by  obviating  the 
conditions  that  prompt  their  use.  Much  contention  has  arisen  in 
the  past  regarding  its  feasibility.  The  writer  notes  with  regret  the 
seemingly  strenuous  tenor  of  these  contentions.  Cases  complicated 
with  gangrene  of  the  lung  and  abundant  fibrinous  deposits  are  cer- 
tainly unsuited  for  the  immediate  use  of  aspiration  treatment. 
Eepeated  experience  with  the  simple  portable  apparatus  devised  by  the 
author  since  the  writing  of  the  preceding  clause  has  not  in  any  degree 
lessened  his  belief  in  its  efficiency,  in  suitable  cases.  On  the  contrary, 
the  rapidity  with  which,  in  nearly  every  instance,  the  size  of  an 
empyemic  cavity  has  been  reduced  by  this  simple  method  of  aspira- 
tion emphasizes  its  worth  in  limiting  the  often  tedious  course  of  this 
affection  in  a  most  decided  manner.     Xow  we,  in  nearly  every  instance, 


THORACOTOMY  405 

introduce  the  tube  into  the  cavity  as  soon  after  resection  or  simple 
incision  as  will  permit  of  the  tissues  being  sufficiently  tightly  drawn 
around  it  with  adhesive  strips  to  prevent  the  entrance  of  air  from  with- 
out. Sometimes  over  these  adhesive  strips,  aseptic  absorbent  cotton, 
wet  with  boric-acid  solution,  is  packed  and  confined  in  place  with  ad- 
hesive strips,  before  air  can  be  excluded,  when  suction  is  applied.  In 
such  cases  care  must  be  taken  to  prevent  air  from  forcing  fragments 
of  cotton  into  the  cavity.  The  apparatus  has  proven  decidedly  effi- 
cient in  those  cases  from  which  fibrin  had  been  removed  or  in  which 
not  enough  was  present  to  obstruct  the  tube ;  also,  in  which  the  walls  of 
a  small  cavity  or  of  a  sinus  were  not  obstructed  from  suction.  The  hol- 
low rubber  cushion  (Fig.  269,  a)  is  not  so  secure  as  the  use  of  adhe- 
sive strips.  In  many  instances  a  glass  chamber  has  been  substituted 
for  the  glass  tube  (a)  and  the  fluids  collected  therein  as  they  were 
withdrawn  by  the  rubber  bag.  In  two  instances  the  tube  was  inserted 
through  a  cannula  deposited  between  the  ribs  by  means  of  a  fitting 
trocar,  the  cannula  being  removed  as  soon  as  the  tube  was  in  place. 
In  those  instances  the  tissues  pinched  the  tube  closely,  especially  when 
suction  was  applied,  and  easily  excluded  the  admission  of  air.  The 
influence  of  force  of  aspiration  on  the  dimension  of  a  cavity  is  best 
appreciated  by  occasional  measurement  through  the  agency  of  water, 
introduced  into  it  with  the  body  always  in  the  same  posture.  Both 
antiseptic  and  aseptic  flushings  are  employed  when  indicated. 

By  the  apparatus  one  can  determine  the  presence  of  minute  lung 
perforations,  as  then  a  vacuum  is  not  maintained. 

Dr.  Bryant  informs  the  writer  that  he  has  quite  abandoned 
the  use  of  the  rubber  cushion  in  these  cases,  as  it  is  difficult  to 
obtain  symmetrical  application  of  the  rubber  to  the  chest  wall  be- 
cause of  the  irregularity  of  the  outline  of  the  latter.  In  most 
cases  he  introduces  the  intrathoracic  portion  of  the  tube,  packs 
the  wound  and  surrounding  tissues  with  absorbent  cotton,  and 
seals  the  surface  with  collodion.  This  measure  is  very  effective 
and  may  be  substituted  for  the  rubber  cushion  if  the  latter  be 
found  defective  in  the  regard  mentioned.  Also,  it  will  not  be 
always  convenient  to  obtain  the  rubber  cushion  at  short  notice, 
and  the  measure  just  discussed  may  be  employed  until  an  espe- 
cially constructed  cushion  is  made,  which  should,  of  course,  be 
fitted  with  the  view  of  obviating  the  objection  mentioned.  If 
a  special  cushion  be  made  for  each  case  its  use  should  be  found 
effectual  for  the  purpose.     The  objection,  on  the  other  hand,  to 


406  OPERATIONS   ON  THE  THORAX 

the  cotton  and  collodion  seal  is  that  it  is  removed  with  difficulty 
when  the  wound  is  to  be  cleansed.  In  this  connection  the  at- 
tendant is  asked  to  bear  in  mind  that  ether  will  dissolve  the  mix- 
ture, and  its  removal  will  be  much  aided  by  its  use. 

It  should  also  be  borne  in  mind  that  the  most  dependent  por- 
tion of  the  pleural  sac  is  posteriorly  and  inferiorly,  and  that 
thoractomy  is  never,  if  ever,  done  at  this  aspect  of  the  chest  wall. 
Thorough  emptying  of  the  empyemic  cavity  is  never  achieved 
except  as  the  outcome  of  suction,  and  when  the  dressing  is 
changed,  whether  the  aspiration  apparatus  has  been  employed  or 
not,  a  rubber  tube  of  sufficient  length  to  reach  the  bottom  of  the 
cavity  should  be  introduced  and  the  contents  removed  by  suction. 
When  flushing  is  employed,  the  lavage  should  be  made  with  ample 
provision  for*  return  flow,  in  order  to  obviate  respiratory  disturb- 
ance from  pressure  of  the  cleansing  fluid  on  the  lung. 

The  cleansing  fluid  should  have  a  temperature  of  105°  F., 
and  be  introduced  with  the  precautions  mentioned.  For  the  pur- 
pose Thiersch' s  solution  or  a  normal  saline  solution,  giving  due 
attention  to  sterility  of  the  agent,  may  be  used.  Solutions  of 
corrosive  sublimate  or  carbolic  acid  should  never  be  employed 
except  in  chronic  inflammatory  conditions  which  have  been  freely 
exposed  by  thoracoplasty  (page  407). 

After  the  return  fluid  is  clear  the  irrigation  is  suspended,  the 
cavity  is  completely  emptied  by  suction,  and  the  aspiration  ap- 
paratus reapplied.  It  is  preferable  to  have  the  patient  in  the 
supine  position  during  the  lavage.  However,  when  suction  is 
made  for  the  purpose  of  completely  emptying  the  pleural  sac, 
the  patient  may  be  sat  up  in  order  to  cause  gravitation  of  the 
fluid  contents  to  the  most  dependent  portion  of  the  cavity  and 
thus  permit  of  its  complete  removal.  During  the  latter  act  due 
care  should  be  exercised  to  obviate  syncope,  as  lavage  of  the 
pleural  cavity  is  not  infrequently  attended  by  considerable  shock 
to  the  patient.  Under  no  circumstances  should  hydrogen  peroxid 
be  used  in  this  class  of  cases,  for  obvious  reasons. 

THORACOPLASTY 

The  resection  of  a  greater  or  lesser  amount  of  contiguous  ribs, 
with  the  view  of  giving  relief  of  chronic  inflammatory  conditions 


THORACOPLASTY  407 

of  the  pleura,  does  not  necessarily  involve  the  use  of  the  agents 
to  obviate  interference  with  respiration,  as  is  the  case  in  opera- 
tions for  more  acute  processes.  This  is,  perhaps,  due  to  the 
fact  that  rarely,  indeed,  is  the  entire  pleural  sac  involved,  and, 
as  a  rule,  compensatory  dilatation  of  the  opposite  air  cells 
has  produced  a  certain  respiratory  balance.  It  is  wise,  how- 
ever, to  be  prepared  for  the  emergencies  in  even  this  class  of  cases 
(page  399). 

After  completion  of  the  resection  the  wound,  as  a  rule,  is  left 
open  and  the  residual  cavity  packed  with  iodoform  gauze.  The 
gauze  is  removed  at  the  end  of  twenty-four  hours  and  the  cavity 
lightly  packed,  this  procedure  being  repeated  every  second  day 
until  obliteration  of  the  cavity  takes  place.  As  in  these  cases 
there  is  ample  provision  for  egress  of  cleansing  agents,  hydrogen 
peroxid  may  be  used  for  the  purpose,  and,  indeed,  its  employ- 
ment is  advised,  with  the  view  of  loosening  the  gauze  which,  in 
some  instances,  becomes  adherent  to  the  pleura.  The  cavity  may 
be  irrigated  with  either  corrosive  sublimate  (1-5,000)  or  carbolic 
acid  1  in  200  solution.  In  those  cases  in  which  the  pleura  is 
much  thickened  the  surface  of  the  cavity  may  be  painted  with 
tincture  of  iodin  with  the  view  of  giving  rise  to  moderate  in- 
flammation and  to  stimulate  the  deposit  of  scar  tissue.  This  may 
be  repeated  every'  four  days. 

As  expansion  of  the  lung  in  these  cases  is  not  to  be  expected, 
and  obliteration  of  the  cavity  is  achieved  as  the  outcome  of  col- 
lapse of  the  chest  wall,  the  latter  should  be  encouraged  by  strap- 
ping the  chest  with  moderate  pressure.  The  irrigation  of  the 
cavity  should  be  done  with  large  quantities  of  solution,  the  tem- 
perature of  which  should  be  about  105°  F.  The  employment  of 
warm  solutions  has  a  tendency  to  obviate  the  shock  attendant 
upon  manipulations  in  this  situation.  As  the  cleansing  is  made 
every  two  days,  or  possibly  oftener,  the  repeated  manipulations 
are  likely  to  exhaust  the  patient.  A  Kelly  pad  (Fig.  13,  page 
49)  may  be  slipped  under  the  patient  and  the  surrounding  sur- 
face of  the  body  protected  with  blankets,  and,  indeed,  the  tech- 
nic  of  the  procedure  should  be  designed  to  obviate,  as  much  as 
possible,  discomfort  and  annoyance  to  the  patient.  As  soon  as  it 
is  feasible,  the  patient  should  be  placed  in  the  open  air  and  the 
over  feeding  begun.      This   is  exceedingly  important,   as  not   a 


408  OPERATIONS  ON  THE  THORAX 

small  number  of  those   afflicted  with  chronic   inflammatory  con- 
ditions of  the  pleura  are  tuberculous. 

As  soon  as  convalescence  is  established  breathing  exercises 
and  gymnastics  should  be  indulged  in.  The  tendency  toward 
lordosis  may  be  in  a  measure  overcome  by  the  employment  of 
these  measures.  The  application  of  apparatus  designed  to  cor- 
rect deformity  of  the  spine  must  be  postponed  until  the  wound 
is  healed.  On  the  whole,  the  wearing  of  apparatus  to  overcome 
spinal  deformity  in  these  cases  is  of  little  service  unless  supple- 
mented by  rational  gymnastics. 

DECORTICATION   OF   THE   LUNG 

Decortication  of  the  lung  and  removal  of  the  parietal  pleura 
limiting  the  empyemic  cavity  calls  for  the  same  preparation  as 
obtains  with  the  procedures  just  discussed.  As,  however,  re- 
moval of  the  pyogenic  membrane  contemplates  expansion  of  the 
lung  and  closure  of  the  wound  in  the  chest  wall,  the  after-treat- 
ment differs,  inasmuch  as  simple  drainage  is  introduced  and  the 
measures  designed  to  promote  expansion  of  the  lung  are  assidu- 
ously practiced  early  in  the  postoperative  care.  Packing  is,  of 
course,  omitted.  The  measure  has  not  been  sufficiently  tested 
to  permit  of  a  conclusion  with  regard  to  its  practicability. 

RESECTION   OF  LARGE   SURFACES   OF   THE   THORACIC 

WALL 

Resection  of  large  surfaces  of  the  thoracic  wall  and  invasion 
of  the  pleural  cavities  for  disease  in  these  situations,  other  than 
inflammatory  conditions  of  the  pleural  sac,  differ  with  regard  to 
the  problem  presented  inasmuch  as  in  the  latter  class  of  cases  the 
lung  is  already  collapsed  or  displaced  to  an  extent  commensurate 
with  the  extent  of  the  affliction,  while  in  the  former  class  of  cases 
the  lung  is  still  in  contact  with  the  thoracic  wall,  and  invasion  of 
the  pleural  sac  or  lung  produces  a  sudden  collapse  of  the  lung, 
and  death  from  embarrassment  of  the  respiratory  function  is 
likely  to  occur.  The  deformity  following  attack  of  the  thoracic 
wall  for  disease  of  the  pleura  is  the  result  of  collapse  of  the  chest 
wall.     In  instances  in  which  the  thoracic  wall  is  opened  for  the 


RESECTION   OF   LARGE   SURFACES   OF   THORACIC   WALL  409 

relief  of  disease  of  the  lung  itself,  healing  takes  place  without 
marked  deformity.  Fig.  274  shows  a  case  in  which  extensive 
resection  of  the  chest  wall  was  made  for  gangrene  of  the  lung. 
It  will  be  seen  that  there  is  no  collapse  of  the  chest  wall  and  that 
no  spinal  deformity  has  occurred.  This  applies  with  equal  force 
to  surgical  invasion  of  the  lung  tissue  itself.     Certain  diseases  of 


Fig.  274. — Appearance  of  Chest  Following  Extensive  Resection 
of  Ribs,  Including  Clavicle  for  Gangrene  of  the  Lung. 
(von   Bergmann.) 

the  lung  are  regarded  as  amenable  to  surgical  treatment,  and  the 
attendant  is  expected  to  have  in  readiness  apparatus  which  will 
obviate  the  danger  of  collapse  of  the  lung. 

The  following  description  is  taken  from  a  communication  to 
Dr.  J.  D.  Bryant  from  the  originator  of  the  apparatus,  Fell 
(Fig.  275),  who  has  improved  the  original  apparatus  in  the 
following  way : 


The  apparatus  which  I  have  used  and  found  so  efficient  in  cases 


410 


OPERATIONS    ON   THE   THORAX 


of  forced  respiration  (Fig.  276)  consists  of  a  bellows  (a),  the  size 
of  which  has  been  determined  by  my  experience.  It  is  operated  as 
follows :  Three  movements  for  inspiration  and  three  for  expiration. 


Fig.  275. — The  Fcll-O'Dwyer  Apparatus  in  Action,  Showing  the  Bellows,  As- 
sorted Sizes  or  Intubation  Cones,  and  the  Conductor.  An  intubation  cone  of 
suitable  size  is  pressed  into  the  larynx  so  as  to  prevent  the  escape  of  air  between  it 
and  the  laryngeal  wall.  The  bifurcated  arrangement  of  the  conductor  regulates 
the  amount  of  air  introduced  by  means  of  the  thumb  acting  as  a  valve  at  the  point 
of  escape.     (Bryant.) 


This  will  produce  eighteen  or  twenty  respirations  per  minute  when 
worked  at  a  convenient  rate  of  speed.  The  attempt  to  operate  it  so 
that  a  single  movement  represents  an  inspiration  would  almost  cer- 


RESECTION   OF   LARGE  SURFACES   OF  THORACIC  WALL  411 

tainly  defeat  the  purpose  for  which  the  apparatus  is  intended.  The 
anesthetic  can  be  administered  by  placing  a  sponge  or  gauze,  prop- 
erly saturated  with  the  anesthetic,  over  or  in  proximity  to  the  open- 


Fig.  276. — Forced  Respiration,  Fell's  Improved  Apparatus.     A,  Bellows;  B,  Air 
valve;   C,  Face  mask.     (Bryant.) 


ing  through  which  the  air  enters  the  bellows.  A  simple  arrangement, 
constructed  on  the  principle  of  the  chemist's  wash  bottle,  by  means 
of  which  oxygen  can  be  made  to  pass  through  a  tube  into  the  air  valve, 
thence  with  the  anesthetic  into  the  lungs,  can  be  attached.  This 
device,  along  with  that  for  mingling  oxygen 
with  the  inspired  air,  makes  a  complete  outfit 
for  the  purpose.  Next  to  the  bellows  is  the  air 
valve  (b)  with  which  it  is  arranged  to  act.  The 
operator  presses  down  the  piston  of  the  valve 
a  full  stroke  during  three  movements  of  the 
bellows,  thus  causing  inspiration  by  permitting 
the  air  saturated  with  the  anesthetic  to  enter 
the  lungs  through  any  one  of  the  selected 
channels,  i.e.,  the  face  mask  (c),  the  intuba- 
tion cone  (Fig.  275),  or  the  tracheotomy  tube 
(Fig.  277).  The  piston  is  then  released  until 
three  movements  of  the  bellows  are  made, 
which  permits  expiration  to  occur.  Before  the 
operation  is  begun  the  mask  should  be  snugly 

fitted  to  the  face  to  prevent  any  uncertainty  in  this  respect.     If, 
during  inspiration,  it  does  not  fit  so  that  the  cheeks  may  bulge 


Fig.  277. —  The  Tra- 
cheotomy Tube  and 
Rings  Used  in 
Forced  Artificial, 
Respiration,  Fell's 
Method.     (Bryant.) 


412  OPERATIONS    ON   THE   THORAX 

without  air  escaping  by  the  side  of  the  mask,  its  action  cannot  be 
attained.  Frequently  a  pad  or  folded  handkerchief  placed  over  the 
bridge  of  the  nose  will  secure  a  tight  fit.  If  an  intubation  tube  be 
employed,  a  rubber  tube  from  the  air  valve  can  be  connected  with  the 
former  and  good  inflation  can  be  secured,  provided  that  the  end  of 
the  tube  is  of  proper  size  to  fit  the  trachea.  My  best  results  in  long- 
continued  respiration  have  been  secured  by  means  of  tracheotomy  and 
the  occluding  of  the  trachea  with  a  suitably  sized  ring  screwed  to  the 
end  of  the  tracheotomy  tube  (Fig.  277).  But  for  operative  work  on 
the  thorax,  the  other  methods  appear  to  be  better  suited.  The  size 
of  the  bellows  and  the  manner  of  its  operation  should  be  suited  to  the 
requirements  of  individual  cases,  i.  e.,  one  movement  for  inspiration 
and  one  for  expiration  in  a  child,  two  movements  for  inspiration  and 
three  for  expiration  in  a  youth,  and  three  for  inspiration  and  the  same 
for  expiration  in  an  adult  will  usually  suffice. 

Various  cabinets  have  been  devised  for  the  purpose,  one  of 
which  has  been  extensively  used  by  Mikulicz.  These  appara- 
tuses are  cumbersome  and  difficult  to  manage.  Their  employ- 
ment in  well-equipped  hospitals  is  found  of  use.  Under  ordi- 
nary conditions  the  Fell  apparatus  will  be  found  to  quite  meet 
the  indications.  It  is  advised  that  in  all  operations  contemplat- 
ing invasion  of  the  pleura  and  lung  and,  indeed,  the  medias- 
tinum, this  apparatus  be  available,  and  that  it  be  employed  in 
the  class  of  cases  alluded  to  above.  With  regard  to  the  invasion 
of  the  mediastinum,  indeed,  in  sectioning  the  sternum  this  ap- 
paratus should  be  available,  as  the  relationship  of  the  pleural 
cavities  to  the  mediastinum  is  so  atypical  as  to,  in  almost  all  in- 
stances, render  their  puncture  exceedingly  liable.  Quite  invari- 
ably surgical  wounds  of  the  pleural  sacs  and  lungs  are  treated  by 
the  open  method.  In  a  few  instances,  such  as  decortication  of 
the  lung  and  parietal  pleura,  and  in  the  rare  instances  where 
malignant  disease  of  these  parts  is  attacked,  the  operation  is  fol- 
lowed by  closure  of  the  wound  in  the  thoracic  wall  and  establish- 
ment of  drainage.  The  admonitions  with  regard  to  the  postopera- 
tive care  of  these  cases,  as  stated  above,  should  be  assiduously 
regarded.  The  attendant  should,  for  obvious  reasons,  be  pre- 
pared to  overcome  shock.  Accidental  infection  should  be  care- 
fully guarded  against  during  the  postoperative  care  of  the  wound, 
as  the  pleural  sacs  are  large  lymph  spaces  from  which  absorption 


THE   DEFORMITY 


413 


of  infective  material  readily  takes  place.  The  infective  process 
calling  for  surgical  interference  has,  in  many  instances,  already 
been  taken  care  of  by  the  tissue  changes  attendant  upon  the  in- 
flammatory process.  The  surgical  trauma  is  quite  likely  to  open 
additional  avenues  for  the  entrance  of  infection,  and  the  newly 
introduced  infection  may  be  of  a  character  which  the  resistance 
of  the  patient  may  not  be  sufficient  to  combat. 

It  is  a  not  uncommon  error  for  practitioners  to  regard  the 
fact  that  empyema  is  an  infective  process  as  making  asepsis  or 
antisepsis  an  unnecessary  indulgence.  The  writer  warns  against 
action  in  accord  with  this  belief,  on  the  grounds  stated. 


THE   DEFORMITY 

The  deformity  following  resection  of  the  thoracic  wall  has  al- 
ready   been    alluded 


to. 


Fig.   278  shows 


a  not  uncommon  ul- 
timate  o u t c o m e . 
This  may  be,  to  a 
considerable  extent, 
prevented  by  gym- 
nastics. The  patient 
should  be  instructed 
to  take  breathing 
exercises  and  to  un- 
dergo exercises  with 
pulleys  designed  to 
obviate  the  spinal 
curvature.  The  ex- 
ercises should  not  be 
sufficiently  arduous 
to  involve  dyspnea, 
though  increase  in 
the  number  of  respi- 
rations is  beneficial. 
If  the  p  a  t  i  e  n  t  be 
compelled  to  earn  his 
livelihood     while 


Fig.  278. 


-Deformity  Following  Extensive  Resec- 
tion of  Rius.     (von  Berc/mann.) 


414  OPERATIONS   ON  THE  THORAX 

seated  at  a  machine  or  desk,  the  chair  he  occupies  should  be  fitted 
with  a  slanting  seat,  so  arranged  as  to  carry  the  curve  of  the  spine 
toward  the  afflicted  side.  Women  should  be  encouraged  to  wear 
corsets  which  do  not  take  the  place  of  muscular  effort.  If,  for 
cosmetic  reasons,  the  patient  be  found  intractable  in  this  connec- 
tion, a  few  hours  a  day  should  be  occupied  without  the  presence 


Fig.  279. — Retraction  of  Flap  Following  Thoracoplasty,  (von  Bergmann.) 

of  the  corest.  In  all  cases  the  general  tone  of  the  patient  should 
be  brought  to  as  high  a  level  as  is  feasible  by  attention  to  diet,  the 
administration  of  tonics,  creosote  and  fat  emulsions.  The  admin- 
istration of  iodin  seems  to  be  of  benefit.  A  mixture  of  syrup  of 
the  iodid  of  iron  in  an  emulsion  of  the  mixed  fats  has  proven  of 
apparent  benefit.  The  causative  factor  which  produced  the  con- 
dition calling  for  operative  relief  is,  of  course,  the  most  determin- 
ing prognostic  element.  However,  even  in  tuberculous  processes, 
a  favorable  ultimate  outcome  will  not  infrequently  prove  sequen- 
tial to  painstaking  attention  to  details  in  the  after-treatment. 


THE   DEFORMITY  415 

Following  thoracoplasty  by  the  flap  method  the  cavity  left 
beneath  the  flap,  not  having  any  osseous  wall,  contracts  and  bulges 
with  deep  respiration  or  coughing.  This  has  been  regarded  as 
the  outcome  of  distention  or  collapse  of  the  lung  (Figs.  279  and 
280). 


Fig.   280. — Bulging  of  Flap  Following  Thoracoplasty,     (von  Bergmann.) 

The  entrance  and  expulsion  of  air  is,  however,  not  the  causa- 
tive factor  in  this  regard.  The  bulging  may  be  produced  by 
keeping  the  glottis  open  and  making  pressure  upon  the  abdominal 
wall  in  an  upward  direction. 

The  phenomenon  need  not  be  regarded  as  rendering  exercise 
of  the  respiratory  function  dangerous.  During  muscular  exer- 
tion the  patient  may  best  be  protected  from  unnecessary  strain 
upon  the  weakened  thoracic  wall  by  wearing  a  firm  pad  over  the 
site  of  the  thoracotomy.  The  retraction  of  the  flap  is,  perhaps, 
of  minor  importance,  and  it  is  probable  that  if  any  unfavorable 
outcome  is  to  be  apprehended,  it  is  from  the  bulging.  The  pre- 
caution mentioned  has  a  tendency  to  obviate  these  contingencies. 


CHAPTER    XX 
OPERATIONS    ON    THE    SPINAL    COLUMN 

Laminectomy — Tuberculosis  osteomyelitis  of  the  spine. 

LAMINECTOMY 

Laminectomy,  or  perhaps  more  properly  stated,  resection  of 
the  vertebral  arches,  for  the  purpose  of  attacking  the  spinal  canal 
does  not  call  for  especial  preparatory  measures  beyond  those  given 
in  connection  with  operations  in  other  situations.  Host  afflic- 
tions of  the  spinal  cord  calling  for  operative  intervention  are  at- 
tended with  certain  trophic  changes  in  the  portions  of  the  body 
located  below  the  seat  of  disease,  and  special  measures  in  after- 
treatment  must  be  carried  out  to  obviate  determining  complica- 
tions. The  trophic  changes  spoken  of  have,  too,  an  influence  in 
the  character  of  the  healing  process  in  the  wound,  and  drainage 
is  usually  made  of  wounds  in  this  situation.  Immediately  after 
the  patient  is  operated  upon,  he  should  be  placed  on  a  water  bed. 
It  is,  of  course,  quite  impossible  to  obviate  absolutely  all  press- 
ure on  the  v\-omi(l.  but  this  should  be  aimed  ,at,  and  the  patient 
postured  on  the  side  as  soon  and  as  long  as  is  possible.  For  the 
purpose  the  attendant  must,  during  the  period  of  semi-conscious- 
ness immediately  following  the  operation,  be  watc-hful  and  pa- 
tient, and  not  leave  the  patient  until  intelligent  cooperation  may 
be  expected.  The  patient  will,  no  doubt,  be  willing  enough  to 
carry  out  instructions  designed  to  obviate  pressure  upon  the 
wound,  but  as  operations  on  the  spinal  cord  are  usually  performed 
at  a  time  when  paralysis  exists,  he  may  not  be  in  a  position  to 
do  so. 

A  lateral  position  should  not  be  maintained  for  more  than 
three  hours,  and  the  patient  should  then  be  rolled  carefully  over 
and  so  lifted  as  to  avoid  trauma  to  the  wound.  Each  morning 
the  patient  should  be  bathed  with  tepid  water  and  sponged  with 

416 


LAMINECTOMY  417 

alcohol.  The  occurrence  of  bed  sores  is  a  very  likely  complica- 
tion following  the  operation,  and  this  should  be  avoided.  It  is 
to  be  borne  in  mind  that  alcohol  does  not  act  specifically  as  a 
preventative  of  bed  sores,  and  the  attendant  must  not  be  content 
with  simply  sopping  the  alcohol  on  the  skin.  Alcohol  simply 
cleanses  and  perhaps  stimulates  nutrition  in  the  skin.  The  most 
effective  preventative  of  bed  sores  is  frequent  change  of  posture, 
assiduous  attention  to  cleanliness,  and  gentle  massage  of  the  skin. 
The  tendency  to  contractures  and  posture  deformities  must  be 
combated  by  passive  motion  of  all  the  limbs,  especially  the  lower 
ones.  Immobilization  of  the  limbs  with  the  view  of  preventing 
deformity  is  unwise  as  ankyloses  which  are  very  obstinate  are 
likely  to  occur.  The  bladder  demands  special  care.  As  a  rule, 
afflictions  of  the  spinal  cord  are  attended  with  paralysis  of  the 
bladder.  This  results  in  overdistention  and  overflow,  the  urine 
dribbling  constantly  into  the  bed.  These  patients  are  reported 
to  the  attendant  as  incontinent,  and  unless  investigation  is  made, 
the  bladder  is  left  filled  and  the  urine  undergoes  decomposition, 
causing  cystitis.  The  bladder  mucosa  becomes  severely  in- 
flammed  and  in  some  instances  sloughs  from  pressure.  The  re- 
sult is  that  fetid  urine  is  discharged,  which  soaks  the  bedclothes, 
and  the  patient  is  left  lying  in  the  putrid  pool  at  times  for  hours. 
Catheterization  of  the  bladder  in  these  cases  should  be  done  every 
six  hours  following  the  operation  and  twice  daily  after  the  third 
day  following  the  operation.  Special  precautions  should  be  taken 
to  prevent  infection  of  the  bladder  or  urethra  during  the  manip- 
ulations, as  they  must,  most  likely,  be  carried  on  for  a  long  pe- 
riod of  time.  Infection  would  make  the  catheterization  a  diffi- 
cult problem. 

In  some  instances,  when  the  bladder  is  unable  to  hold  any 
urine  whatever,  it  is  best  to  introduce  the  "  mushroom  "  reten- 
tion catheter  (Fig.  354).  The  bladder  should  not  be  irrigated 
unless  infection  occurs.  However,  it  is  not  probable  that  cystitis 
will  be  avoided  when  the  retention  catheter  is  employed ;  so  in 
these  instances  lavage  of  the  bladder,  once  daily  with  a  mild  so- 
lution of  potassium  permanganate  (1  in  1,000),  should  be  prac- 
ticed. For  the  purpose  no  undue  force  should  be  employed  in 
injecting  the  fluid,  and  no  more  than  six  ounces  of  fluid  pro- 
jected into  the  bladder  at  one  time,  when  it  is  immediately  al- 


418  OPERATIONS   ON  THE  SPINAL  COLUMN 

lowed  to  run  out.  In  these  cases  no  residual  cleansing  fluid  is 
permitted  to  remain  in  the  bladder.  The  mushroom  catheter 
should  be  removed  at  the  end  of  twenty-four  hours,  and  the 
urethra  cleansed  by  the  Janet-Chetwood  method  (page  584").  Ure- 
thritis and  its  complications  may  be  avoided  in  this  way.  An- 
other retention  catheter  is  introduced  and  the  one  removed  is 
sterilized  and  kept  submerged  in  sterile  water  until  it,  in  turn, 
is  introduced  at  the  next  sitting.  The  distal  end  of  the  catheter 
is  connected,  by  means  of  a  glass  tube,  with  a  long  rubber  tube, 
which  is  led  into  a  bottle  partially  filled  with  a  solution  of  car- 
bolic acid  1  in  100.     The  bottle  is  affixed  to  the  side  of  the  bed. 

This  measure  is  far  more  satisfactory  than  placing  a  recep- 
tacle between  the  patient's  legs  to  receive  the  end  of  the  catheter. 
These  receptacles  will  be  upset  and  the  bed  soiled,  and,  again, 
the  posture  of  the  patient  is  much  more  readily  varied  if  the 
measure  suggested  is  employed.  Incontinence  of  feces  is  a  much 
more  difficult  problem  than  that  of  urine.  The  character  of  the 
food  should  be  such  as  not  to  produce  liquid  stools,  and  a  daily 
saline  enema  should  be  given.  The  latter  cleanses  the  lower 
bowel,  and  in  this  way  the  leakage  of  feces  may  be.  in  a  measure, 
controlled.  The  administration  of  cathartics  should  be  avoided, 
and  if  constipation  alternate  with  diarrhea,  the  saline  irrigation 
will  be  found  to  serve  the  purpose  in  each  instance.  The  anus 
should  be  cleansed  with  tepid  water  applied  with  cotton  to  avoid 
the  irritation  produced  by  the  usual  materials  employed  for  the 
purpose. 

It  will  be  seen  that  the  execution  of  the  measures  here  sug- 
gested will  demand  almost  continuous  attention  to  the  patient. 
This  is  true,  and,  indeed,  it  is  suggested  that  operative  attack 
upon  the  spinal  cord  should  not  be  undertaken  unless  the  condi- 
tions can  be  made  to  conform  to  the  necessities.  Celiotomy  and, 
indeed,  many  other  major  operations  do  not  always  demand  spe- 
cially skilled  after  care,  though,  indeed,  this  should  be  obtained 
when  feasible.  With  operations  on  the  spinal  cord,  the  proposi- 
tion is  constantly  and  invariably  a  complicated  one,  and  they 
should  not  be  undertaken  except  in  well-appointed  quarters. 

The  care  of  the  wound  following  laminectomy  is  quite  similar 
to  that  following  operations  in  other  portions  of  the  body.  As 
already  stated,  the  nutritive  changes  in  the  soft  parts,  the  out- 


LAMINECTOMY  419 

come  of  injury  to  the  trophic  centers  in  the  cord,  renders  primary 
union  in  the  wound  quite  unlikely.  In  any  event,  free  drainage 
should  be  established.  If  the  subdural  space  has  been  invaded, 
free  discharge  of  cerebrospinal  fluid  occurs,  and  this  must  not 
be  permitted  to  soil  the  dressing  for  any  considerable  period  of 
time.  In  this  event  the  dressing  should  be  changed  twice  daily 
or  more  frequently  if  necessary,  the  number  of  changes  of  dress- 
ing in  the  day  being  regulated  by  the  amount  of  discharge  of 
fluid.  As  stated  in  connection  with  the  discharge  of  cerebro- 
spinal fluid  following  invasion  of  the  brain  and  its  membranes, 
it  is  best  to  protect  the  wound  with  an  antiseptic  protector.  For 
the  purpose  the  layer  of  gauze  remote  from  the  wound  may  be 
of  the  kind  impregnated  with  corrosive  sublimate,  iodoform,  vio- 
form,  etc.  The  layer  of  gauze  nearest  the  wound  should  not  be 
medicated  for  fear  that  dermatitis  may  occur  as  the  result.  The 
skin  in  this  situation  is,  indeed,  most  likely  to  develop  inflamma- 
tion for  the  reasons  stated  above. 

Textile  fabric  drainage  in  the  form  of  the  "  cigarette  drain  " 
(Fig.  154)  is  perhaps  the  most  useful  agent  for  the  purpose, 
though  silk-worm  gut  (Fig.  147)  may  suffice  in  some  instances. 
The  wound  is  best  held  in  apposition  by  silk-worm  gut  sutures, 
for  the  reasons  already  frequently  discussed  in  this  work. 

Laminectomy  for  fracture  of  the  vertebras  contemplates  re- 
moval of  the  offending  fragments  of  bone.  Necrosis  of  bone  does 
not  frequently  follow  the  operation,  as  the  vertebra?  are  amply 
supplied  with  blood.  However,  it  does  occur,  and  the  complica- 
tion must  be  borne  in  mind  with  the  view  of  determining  the  time 
when  the  drainage  agent  may  be  permanently  removed.  The 
necrosis  is  likely  to  be  only  superficial,  but  will,  nevertheless, 
give  rise  to  a  rather  brisk  reactionary  inflammation  if  opportu- 
nity for  free  egress  be  not  made.  In  this  class  of  cases  it  is, 
therefore,  best  to  maintain  drainage  for  two  weeks  following  the 
operation,  and  the  sutures  may  be  left  in  situ  for  the  same  period 
of  time.  The  textile  fabric  drain,  if  employed,  may  be  removed 
on  the  fifth  day  following  the  operation,  and  for  the  remaining 
portion  of  the  two  weeks  mentioned  silk-worm  gut  drainage  may 
be  used.  If  at  the  end  of  this  period  of  time  there  be  no  evidence 
of  dead  bone,  the  drain  may  be  removed.  If,  however,  the  dis- 
charge from  the  drainage  wound  take  on  the  characteristic 
29 


420  OPERATIONS   ON  THE  SPINAL  COLUMN 

"  prime-juice "  character,  indicative  of  dead  bone,  the  drainage 
must  be  maintained  until  the  discharge  takes  on  the  character- 
istics of  clear  serum,  when  the  drain  may  be  removed. 

TUBERCULOUS    OSTEOMYELITIS   OF   THE   SPINE 

Tuberculous  osteomyelitis  of  the  spine  is  subjected  to  sur- 
gical attack  when  so-called  cold  abscess  forms,  or  when  a  puru- 
lent infection  is  superadded  to  the  tuberculous  process.  The 
operation  consists  usually  of  simple  drainage  of  the  abscess  cavity, 
though  in  some  instances  free  incision  and  packing  of  the  wound 
is  employed.  It  is,  perhaps,  permissible  to  stretch  the  scope  of 
this  book  sufficiently  to  state  that  the  latter  method  of  relief  is 
the  wiser.  Simple  incision  and  drainage,  the  valvular  approach, 
and  similar  measures  of  relief  are  all  procrastination.  No  patho- 
logical process  is  benefited  by  anything  so  much  as  by  its  radical 
removal.     If  this  be  feasible  it  should  always  be  done. 

Cold  abscess  usually  points  at  the  space  of  Petit,  though  al- 
most any  portion  of  the  back  may  be  the  site  of  its  local  manifes- 
tation in  a  certain  small  percentage  of  cases.  After  the  abscess 
has  been  freely  incised  and  its  walls  curetted,  the  cavity  is  packed 
with  iodoform  gauze  in  the  manner  shown  in  Fig.  223.  This 
packing  is  left  in  situ  for  forty-eight  hours,  when  it  is  removed 
in  the  manner  already  described  in  connection  with  the  treatment 
of  infected  wounds. 

It  must  be  remembered  that  tuberculous  osteomyelitis  of  the 
spine  has  its  primary  focus  almost  invariably  in  the  body  of  the 
vertebrae,  and  that  an  attempt  to  obtain  communication  with  the 
seat  of  the  bone  infection  should  be  made.  For  the  purpose  a 
strip  of  the  gauze  packing  should  be  carried  well  down  toward 
the  body  of  the  vertebra?,  with  the  view  of  supplying  an  avenue 
of  escape  for  the  necrosed  bone  and  inflammatory  discharges. 
After  the  wound  takes  on  a  healthy  appearance,  the  spine  should 
be  immobilized  in  a  plaster-of-Paris  jacket  and  a  window  cut  in 
it  corresponding  to  the  site  and  area  of  the  wound.  As  the  dis- 
charge from  the  wound  is  liable  to  find  its  way  between  the  skin 
and  the  plaster  cast,  the  wound  must  be  dressed  every  day  and  the 
edges  of  the  plaster  cast  contiguous  to  the  wound  protected  with 
oil  silk. 


TUBERCULOUS   OSTEOMYELITIS   OF   THE  SPINE  421 

As  soon  as  the  spine  is  immobilized,  the  patient  is  permitted 
to  go  about  or  at  least  is  wheeled  into  the  open  air  in  a  chair. 
!No  attempt  should,  however,  be  made  to  send  the  patient  to  re- 
mote health  resorts  unless  he  be  attended  by  some  one  skilled  in 
the  care  of  the  wound.  An  added  infection,  suppurative  in  char- 
acter, is  exceedingly  undesirable  at  this  time,  for  obvious  reasons. 
The  usual  dietary  treatment  used  in  tuberculosis  must  be  em- 
ployed, and  this  begun  as  soon  after  the  operation  as  is  feasible. 
Prompt  immobilization  of  the  spine,  as  indicated,  will  tend  to 
obviate  the  distressing  deformity  which  is  so  largely  the  sequel 
of  this  affliction. 

As  tuberculosis  of  bone  is  quite  constantly  an  expression  of 
tuberculosis  elsewhere,  an  attempt  should  be  made  to  locate  the 
port  of  entrance  of  the  infection,  and  this  should  be  subjected  to 
appropriate  treatment. 

Above  all  cases  of  this  sort  must  not  be  confined  to  bed  any 
longer  than  is  absolutely  necessary  Immobilization  of  the  spine 
is  quite  feasible  very  soon  after  the  operation,  the  window  used 
for  the  local  treatment  of  the  wound  being  in  no  wise  an  inter- 
ference in  this  connection. 

If  it  be  necessary  to  cut  away  considerable  areas  of  the  jacket 
with  the  view  of  obtaining  the  necessary  amount  of  room  for 
proper  care  of  the  wound,  the  jacket  may  be  reinforced  at  its 
lateral  sides  by  burying  strips  of  galvanized  steel  in  the  layers  of 
the  plaster-of-Paris  bandages. 


CHAPTEE    XXI 

OPERATIONS    ON    THE    ABDOMEN 

Celiotomy — Special  preparation  of  the  gastrointestinal  canal  —  Sterile  diet — 
Drainage — Closure  of  abdominal  wound — Drainage  of  superficial  wound — 
The  protective  dressing — After-treatment  following  celiotomy. 

CELIOTOMY 

Celiotomy  is  at  the  present  time  so  frequently  performed  that 
a  few  additional  remarks  with  regard  to  the  special  preparation 
of  patients  about  to  be  subjected  to  surgical  invasion  of  the  peri- 
toneal sac  seem  justified.  It  is  true  that  recent  investigations 
tend  to  prove  that  the  peritoneum  is  not  as  vulnerable  with  re- 
spect to  infection  as  was  formerly  believed,  and  this  is  ascribed 
to  the  fact  that  this  membrane  represents  a  lymph  space  and  con- 
sequently is  regarded,  in  the  light  of  the  function  of  the  lym- 
phatic system,  as  capable  of  causing  certain  modification  in  the 
constituents  of  pyogenic  material  which  renders  toxic  effects  less 
liable  so  far  as  the  blood  is  concerned.  It  must  be  remembered, 
however,  that  a  too  great  complacency  in  this  connection  is  a 
dangerous  viewpoint  to  take  regarding  the  problem,  and  one 
which  is  to  be  deprecated. 

It  is,  indeed,  true  that  purulent  collections  which  have  been 
in  contact  with  restricted  areas  of  the  peritoneum  for  a  consid- 
erable period  of  time  will  not,  upon  liberation  and  contact  with 
contiguous  portions  of  the  peritoneum,  give  rise  to  additional  in- 
fection. Yet  there  is  no  means  of  ascertaining  at  the  time  of  the 
operation  whether  the  infectiousness  of  the  process  has  been  ex- 
hausted or  whether  sufficient  virulence  is  still  present  which, 
when  the  new  field  of  invasion  presents,  may  develop  a  seriously 
menacing  inflammation.  Clinically  it  not  seldom  happens  that 
the  invasion  of  the  female  pelvis  for  relief  of  pyosalpinx  of  long- 
standing, which  involves  soiling  of  the  peritoneum  with  pus,  is 

422 


CELIOTOMY  423 

followed  by  an  acute  septic  peritonitis  and  death  under  condi- 
tions which  makes  infection  from  without  during  the  operative 
procedure  exceedingly  improbable,  and  must  be  ascribed  to  that 
contamination  from  the  suppurative  process  which  had  been  lo- 
cally confined  and  mechanically  walled  off  by  adhesive  peritonitis 
when  brought  in  contact  with  heretofore  uninfected  areas. 

The  accidental  introduction  of  infection,  while  objectionable 
in  all  portions  of  the  body,  is  not  as  frequently  followed  by  se- 
vere symptoms,  death,  and  serious  sequels  as  obtains  in  the  peri- 
toneal sac.  The  rules  laid  down  above  should  be  carefully  fol- 
lowed with  the  view  of  avoiding  these  contingencies.  Celiotomy 
made  with  the  view  of  invading  the  lumen  of  the  gastrointestinal 
tract  calls  for  additional  preparation,  which  will  be  presently 
taken  up.  In  this  connection  it  is  proper  to  state  that  invasion 
of  the  lumen  of  the  gut  means  contamination  of  the  operative 
field  to  a  greater  or  lesser  degree  in  all  instances.  A  slight 
amount  of  infective  invasion  will  be  taken  care  of  by  the  natural 
resistance  of  the  peritoneum.  The  technic  of  asepsis  should, 
therefore,  be  directed  toward  limiting  the  infective  possibilities 
to  the  unavoidable  amount,  and  for  this  reason  each  step  of  the 
preparation  for  operation  should  be  subjected  to  painstaking  di- 
rectorate to  this  end.  The  situation  may  be  illustrated  by  the  fact 
that  an  appendectomy,  which  involves  but  a  meager  solution  of 
continuity  of  the  gut,  is  more  liable  to  be  followed  by  infection 
than  a  hysterectomy  for  a  large  fibroid  tumor.  Clinical  experi- 
ence will  be  found  to  bear  out  this  statement.  Practitioners  who 
remove  tumors  from  the  abdomen  in  country  practice  and  con- 
tend that  infection  does  not  complicate  their  cases  should  bear 
in  mind  that  their  results  are  not  so  favorable  in  cases  when  the 
gut  is  opened.  The  contention  that  asepsis  need  not  be  so  as- 
siduously employed  in  the  country,  on  the  ground  that  septic 
bacteria  do  not  exist  largely  in  less  closely  populated  districts, 
can,  of  course,  not  include  in  this  belief  the  Communis  coli,  which 
is  the  normal  resident  of  the  gastrointestinal  canal  even  in  the 
arctic  regions,  where  sterility  as  regards  infective  bacteria  is  quite 
commonly  found  to  exist. 

In  a  general  way,  it  may  be  said  that  celiotomy  should  not  be 
made  without  forty-eight  hours'  preparation  of  the  patient,  if 
this  be  consistent  with  the  indications.     Invasion  of  the  gastro- 


424  OPERATIONS   ON   THE  ABDOMEN 

intestinal  canal  should  be  preceded  by  preparation  extending 
over  four  days  if  the  conditions  warrant  this  delay.  Observance 
of  these  admonitions  will  be  found  to  conserve  most  the  best  in- 
terests of  the  patient  as  regards  immediate  and  ultimate  outcome 
of  surgical  intervention  in  this  situation. 

The  primary  incision,  which  sections  the  skin  and  muscle  to- 
gether with  their  fascial  inclosures,  should  be  made  with  instru- 
ments which  are  then  discarded  and  replaced  by  fresh  ones.  For 
this  purpose  the  knife  and  scissors  should  be  duplicated.  Ample 
provision  should  be  made  for  gauze  packing,  and  a  large  number 
of  abdominal  pads  (Fig.  23,  page  TO)  should  be  provided. 
These — the  pads — should  be  counted  and  their  number  recorded 
for  comparison  before  the  abdominal  wound  is  closed,  to  prevent 
the  accidental  retention  of  a  pad  in  the  abdomen,  an  occurrence 
which,  unfortunately,  is  not  uncommon.  The  same  rule  should 
be  applied  to  instruments,  especially  artery  forceps,  all  of  which 
should  be  accounted  for  before  the  peritoneal  sac  is  sutured,  in 
accord  with  the  original  tabulation  recorded  before  the  opera- 
tion. A  copious  saline  lavage  should  be  provided  for,  and  the 
paraphernalia  necessary  to  its  employment  be  at  hand  (page  114, 
et  seq.). 

The  local  preparation  of  the  patient  should  receive  especial 
attention,  and  when  the  patient  is  postured  on  the  operating 
table,  the  body  should  be  placed  in  such  relationship  to  the 
mechanism  of  the  table  as  to  permit  of  change  of  posture,  such 
as  the  Trendelenburg  position,  without  disturbance  of  the  sterile 
surroundings  contiguous  to  the  operative  field,  a  contingency 
which  is  liable  to  cause  exasperating  delay  in  the  operative  pro- 
cedure. As  operations  involving  the  abdominal  cavity  are  fre- 
quently attended  with  shock  of  more  or  less  intensity,  ample  pro- 
vision should  be  made  to  meet  its  occurrence  (page  227). 

SPECIAL  PREPARATION   OF   THE   GASTROINTESTINAL 

CANAL 

The  special  preparation  of  the  gastrointestinal  canal  together 
with  the  month  and  pharynx  contemplates  achieving  comparative 
sterility  of  the  canal.  The  treatment  of  the  mouth  and  pharynx 
has  already  been  stated   (page  362),  and  need  not  be  repeated 


SPECIAL   PREPARATION   OF   GASTROINTESTINAL  CANAL   425 

here.  The  portion  of  the  text  devoted  to  the  question  of  diet  and 
cleansing  of  the  gastrointestinal  canal,  and  the  discussion  of  its 
rationale,  is  taken  from  Moynilian,  whose  masterly  summary  of 
the  situation  may  be  regarded  as  standard  in  accordance  with  the 
present  condition  of  the  sciences. 

Sterility  of  the  digestive  tract  in  its  entirety  is  probably  not 
attainable.  The  aim  is  to  reduce  the  number  of  bacteria  in  it. 
The  newborn  enters  the  world  with  a  sterile  digestive  tract,  a  fact 
Billroth  first  called  attention  to.  Contamination  with  bacteria 
occurs  a  few  hours  after  birth.  Moynilian  regards  the  question 
of  the  bacteriology  of  the  alimentary  tract  as  sorely  in  need  of 
elucidation.     He  states: 

The  exact  origin  of  the  Bacillus  coll,  which  is  the  constant  inhabi- 
tant of  the  intestinal  canal  in  man,  has  never  been  satisfactorily  deter- 
mined, but  there  can  be  little  doubt  that  the  infection  takes  place 
through  the  mouth,  and  that  the  vehicle  is  the  food.  It  is  to  Esclierich 
that  we  owe  a  recognition  of  the  fact  that  the  Bacillus  coli  is  the  char- 
acteristic organism  of  the  human  intestine,  and  that  it  remains  an 
unvarying  inhabitant  throughout  life. 

A  bacterial  invasion  of  the  intestinal  canal  is  not  essential  to  the 
life  or  health  of  the  individual.  Experimental  work,  which  has  been 
amply  confirmed,  has  shown  that  life  may  be  sustained  in  young 
animals  whose  food,  and  whose  surroundings  are  sterile.  Nuttall  and 
Thierfelder  obtained  a  guinea  pig  from  its  mother  by  Cesarean  sec- 
tion, and  placed  it  at  once  in  a  sterile  chamber,  supplied  with  sterile 
air,  and  fed  it  upon  sterilized  foods.  At  the  end  of  eight  days  the 
animal,  which  was  thriving,  was  killed  and  its  intestinal  contents  found 
to  be  sterile.  Levin  investigated  the  bacterial  conditions  in  the  intes- 
tinal canals  of  animals,  bears,  seals,  etc.,  in  Spitzbergen,  and  found 
that,  as  a  rule,  the  contents  of  the  bowel  was  sterile.  In  the  arctic 
regions,  of  course,  there  is  a  great  scarcity  of  organisms  both  in  the 
air  and  in  water. 

Within  the  first  few  hours  of  life  the  intestinal  contents  cease  to 
be  sterile ;  organisms  can  always  be  found.  Of  these  organisms  two 
varieties  are  described — the  permanent  and  the  transient.  The  per- 
manent variety  in  man  is  the  Bacillus  coli,  the  transient  includes  any 
that  are  introduced  into  the  intestinal  canal  by  the  food.  It  is  obvious, 
if  any  organism  whatever  be  introduced  deliberately  into  the  stomach 
with  the  food,  it  will  remain  for  a  shorter  or  longer  time  an  inhabitant 
of  the  alimentary  canal.     But,  as  Gillespie  and  Miller   have   shown, 


426 


OPERATIONS    ON   THE   ABDOMEN 


when  the  bacteria  are  introduced  in  this  way,  there  is  a  steady  decrease 
in  their  numbers  as  digestion  proceeds  and  in  proportion  to  the  increase 
in  the  acidity  of  the  gastric  contents.  According  to  Miller,  at  the  end 
of  nine  hours  the  stomach  contains  no  organisms.  In  the  duodenum 
the  number  of  organisms  is  small ;  but,  the  further  down  in  the  intes- 
tine is  the  material  from  which  the  examination  is  made,  the  more 
numerous  are  the  organisms,  until  the  ileocecal  valve  is  reached.  In 
the  large  intestine  the  bacteria  are  again  few  in  number.     Gilbert  and 

Jlo.afjerTns 
per  Tny- 
100,000 


Stomach.  Duodenum..      Jejurm^n,      Ileum,  L.amelntesbuu! 

Fig.  281. — Gilbert  and  Domenici's  Diagram  Showixg  the  Relative  Ntjmber  of 
Bacteria  P.resext  ix  the  Coxtexts  of  Differext  Parts  of  the  Allmextary 
Tract.  The  dogs  were  killed  three  hours  after  a  meal  of  bread  and  meat.  Ex- 
amination of  the  intestinal  contents  at  this  stage  of  digestion  showed  an  abundance 
of  organisms  in  the  stomach,  a  pronounced  diminution  in  number  at  the  duodenum, 
followed  by  a  gradual  rise  to  the  ileocecal  valve,  where  bacteria  flourish  in  the 
greatest  luxuriance.  When  the  large  intestine  is  reached  there  is  a  marked  falling 
off  in  number,  with  a  slight  rise  proportionate  to  the  distance  from  the  cecum. 
{Harvey  dishing.)      From  Moynihan. 

Domenici  have  presented  diagrammatically  the  average  bacterial  viru- 
lence of  the  alimentary  canal  of  dogs.      (Fig.  281.) 

Harvey  Cusliing  has  investigated  the  conditions  in  cases  of  intes- 
tinal fistula.  In  a  case  of  jejunal  fistula  a  glass  of  milk  could  be 
entirely  recovered  within  a  few  minutes  of  its  ingestion,  with  its  bac- 
teriological features  practically  unchanged.  The  importance  of  the 
physical  characters  of  the  food  is,  therefore,  considerable.  If  the  in- 
gesta  be  fluid  they  are  passed  rapidly  onward  into  the  duodenum 
and  are  but  little,  if  at  all.  altered  by  transit  through  the  stomach. 
If  the  food  be  solid,  it  will  remain,  perhaps  for  hours,  in  the  stomach, 
subject  throughout  this  time  to  the  action  of  the  gastric  juice,  and 
when  passed  into  the  duodenum  it  will  have  the  number  of  bacteria 
greatly  reduced.  Maefadyen,  quoted  by  Cusliing,  has  shown  that  the 
bacillus  of  anthrax,  an  organism  easily  killed  by  the  gastric  juice, 
cannot  be  recovered  by  the  intestine  when  taken  after  a  full  meal,  but 


SPECIAL   PREPARATION   OF   GASTROINTESTINAL  CANAL  427 

when  administered  with  a  large  amount  of  liquid  on  an  empty  stomach, 
its  recovery  from  the  lower  bowel  is  easy.  In  one  of  dishing' 's  cases, 
the  Bacillus  prodigiosus,  an  organism  especially  susceptible  to  the 
action  of  gastric  juice,  could  be  easily  recovered  from  a  jejunal  fistula 
after  its  ingestion  with  inoculated  milk. 

When  the  stomach  has  emptied  itself  of  food,  either  fluid  or  solid, 
the  mucous  membrane  is  sterile;  the  small  amount  of  material  that 
can  be  scraped  from  the  mucous  surface  contains  no  organisms.  Mar- 
fan and  Bernard  have  shown  that  the  same  applied  to  the  intestine; 
that  when  any  part  of  the  intestine  has  emptied  itself  of  its  contents, 
it  becomes  amicrobic.  In  cases  of  artificial  anus  in  man,  the  distal 
loop  of  the  bowel,  so  long  as  it  remains  empty,  is  always  found  to  be 
sterile.  If  from  any  reason  the  stomach  is  unable  to  empty  itself 
satisfactorily,  leaving  always  some  food  stagnant,  the  natural  amicrob- 
ism  can  never  be  attained.  Cashing  writes :  "  It  is,  I  believe,  depend- 
ent only  upon  interference  with  the  stomach's  power  completely  to 
expel  its  contents  that  the  bacterial  life  may  persist  in  its  lumen.  The 
same  principle  holds  true  for  the  duodenum,  and  it  is  not  improbable 
that  a  similar  amicrobic  state  following  digestion,  with  a  canal  com- 
pletely free  from  food  and  the  accompanying  bacteria,  may  be  brought 
about  as  far  down  as  a  condition  of  emptiness  may  be  reached  through 
fasting."  In  a  dog  that  had  been  starved  for  several  days,  the  upper 
part  of  the  intestine  was  found  sterile.     The  accompanying  diagram 


100,000 
$0,000 
10,000 
70,000 
60,000 
50,000 
40.000 
30.019 
10,000 
10,000 

a 


Stomach.  Huodenum    Jejunum.         Ileum.       Cecum. 


Rectum. 


Fig.  282. — Harvey  Cushing's  Diagram  Showing  the  Relative  Number  or  Micro- 
organisms at  Different  Levels  of  a  Dog's  Intestine  After  Prolonged 
Fast.      (Moynihan.) 


(Fig.  282)  which  Gushing  gives  may  be  contrasted  with  that  of  Gil- 
bert (Fig.  281).  It  will  be  seen  that  all  that  portion  of  the  intestine 
which  can  be  rendered  empty  is  by  this  means  alone  rendered  sterile, 
also.  Conversely,  in  cases  of  acute  or  chronic  intestinal  obstruction 
where  the  bowel  has  been  unable  to  empty  itself  for  days  or  for  weeks, 


428  OPERATIONS   ON  THE   ABDOMEN 

the  intestinal  contents  are  teeming  with  bacterial  life.  The  Bacillus 
coli  and  streptococci  are  found  in  great  numbers,  and  their  virulence 
is  extreme. 

The  conclusions  which  may  be  stated  are  as  follows : 

1.  The  stomach  contains,  immediately  after  a  meal,  a  number  of 
microorganisms  of  different  varieties,  according  to  the  nature  of  the 
food  administered. 

2.  If  the  food  is  given  in  liquid  form,  it  is  rapidly  passed  onward 
into  the  intestine,  and  the  bacterial  forms  are  but  slightly,  if  at  all, 
affected. 

3.  If  food  is  given  in  solid  form,  it  remains  longer  in  the  stomach, 
and  the  number  of  bacteria  contained  therein  undergoes  a  steady 
diminution  until  digestion  is  complete.  The  empty  stomach  is  then 
amicrobic. 

4.  The  duodenum  is  often  sterile;  the  number  and  virulence  of 
bacteria  of  the  intestine  increase  in  proportion  to  the  distance  from 
the  duodenum,  and  attain  their  maximum  at  the  ileocecal  valve. 

5.  The  Bacillus  coli  communis  is  the  characteristic  organism  of  the 
human  intestine ;  it  is  never  absent  after  the  first  few  days  of  life. 

6.  The  stomach  and  the  upper  part  of  the  jejunum  can  be  rendered 
sterile  by  administering  only  sterilized  foods  and  by  attention  to  the 
toilet  of  the  mouth.  In  dogs,  starvation  for  a  few  days  leaves  the 
upper  part  of  the  intestine  empty  and  sterile. 

7.  The  stomach  and  intestine,  when  their  contents  have  been  dis- 
charged and  they  are  empty,  are  sterile.  If  the  emptying  is  prevented 
by  obstruction  at  the  pylorus,  or  in  the  intestine,  the  contents,  dammed 
up  behind  the  block,  contain  organisms  whose  number  and  whose  viru- 
lence are  greatly  increased. 

The  importance  of  these  facts  from  the  surgical  point  of  view  is 
that  they  show  what  is  to  be  expected  in  cases  of  perforation  of  the 
stomach  or  intestine,  and  they  demonstrate  the  possibility  of  rendering 
sterile,  for  purposes  of  operation,  the  stomach  and  upper  part  of  the 
intestinal  canal.  For  example,  when  peritonitis  results  from  a  per- 
foration high  up  in  the  intestine,  the  offending  microorganism  is 
generally  a  streptococcus;  when  the  perforation  is  low  down  in  the 
intestine,  the  Bacillus  coli  is  the  most  abundant  or  the  only  organism. 

It  is  to  Dr.  Harvey  Cusliing,  of  Baltimore,  that  we  are  indebted 
for  calling  the  attention  of  surgeons  to  the  possibility  of  rendering  the 
stomach  and  intestine  sterile  as  a  preparatory  measure  to  operations. 
He  wrote,  in  a  very  able  paper  from  which  I  have  freely  quoted  (vol. 
IX,  Johns  Hopkins  Hospital  Reports)  : 

The  procedure  which  we  have  employed  is  simple  and  mainly  con- 


SPECIAL   PREPARATION   OF   GASTROINTESTINAL  CANAL  429 

sists  in  an  attempt  to  render  amicrobic  all  ingesta.  The  mouth  is 
rinsed  with  an  antiseptic  solution  and  the  teeth  are  carefully  brushed 
at  intervals  of  a  few  hours,  and  with  especial  care  before  and  after 
feeding.  The  stomach,  if  any  chronic  catarrh  exists  and  microorgan- 
isms in  number  are  found  present  after  a  test  meal,  is  washed  out  care- 
fully morning  and  evening.  Food  is  taken  in  small  amounts  and  at 
comparatively  frequent  intervals,  from  clean  or,  preferably,  sterile 
vessels,  and  consists  of  boiled  water,  sterilized  milk,  beef  tea,  albumin 
water,  and  similar  liquids.  Patients  with  chronic  gastritis  have  been 
seen  to  gain  weight  under  this  regime.  Preliminary  to  the  operation 
for  from  six  to  ten  hours  nothing  is  given  by  mouth,  rectal  feeding 
being  instituted  if  necessary. 

Many  drugs  have  been  given  in  the  hope  that  by  their  aid  the  intes- 
tinal contents  could  be  rendered  sterile.  Among  such  are  /3-naphthol, 
salol,  iodoform,  and  actol,  to  mention  only  a  few.  All  have  proven 
useless.  Eecently  Adolph  Hoffmann  (Mittheilungen  a.  d.  Grenz- 
gebiet.  1906.  Bd.  15  Heft  5.  P.  596)  has  recorded  a  series  of  observa- 
tions made  upon  the  intestinal  contents  recovered  from  fistuhe, 
colotomy  openings,  and  enterostomy  openings  after  the  administration 
of  isoform.  This  drug  is  administered  in  powder  or  in  capsules,  or 
in  both  together,  the  dose  being  3  grammes,  given  in  quantities  of  y2 
gramme,  within  a  period  of  two  to  twenty-four  hours.  The  effect  was 
remarkable  and  constant.  The  number  of  colonies  that  could  be  cul- 
tivated from  the  discharge  was  enormously  reduced  in  all  cases.  The 
rapidity  with  which  the  effect  upon  the  contents  was  produced 
depended  upon  the  part  of  the  alimentary  canal  from  which  cultures 
were  taken.  In  cases  of  pyloric  disease  the  effect  upon  the  stomach 
contents  was  noticed  in  a  few  minutes  if  the  drug  was  administered 
in  powder.  Isoform  is  supplied  in  powder  and  in  capsules,  hardened 
and  unhardened — the  latter  dissolve  in  about  an  hour  and  a  half  in 
the  stomach,  setting  free  the  drug;  the  former  pass  into  the  intestine, 
where  they  are  dissolved  in  a  variable  and  often  uncertain  time.  In 
the  intestine  an  undoubted  effect  is  produced  in  thirty  hours  from 
the  administration  of  the  dose.  Though  3  grammes  is  the  usual 
dose,  as  much  as  7  to  8  grammes  have  been  given  to  the  adult  male 
without  producing  distress.  The  symptoms  which  come  from  an  ex- 
cessive dose,  or  from  too  frequently  repeated  doses,  are  loss  of  appe- 
tite, vomiting,  and  a  feeling  of  sickness. 

Acetozone' dissolved  in  sterile  water  is  a  useful  agent  in  this 
connection.  About  seven  and  a  half  grains  are  added  to  a  half 
pint  of  hot  water,  and  to  this  a  half  pint  of  cold  sterile  water  is 


430  OPERATIONS  ON  THE  ABDOMEN 

added.  The  patient  sips  this  in  place  of  pure  water  as  a  beverage 
between  feedings.  The  greatest  field  of  usefulness  of  the  agent 
is  as  a  preparatory  measure  in  operations  on  the  stomach.  The 
writer  uses  it  preliminary  to  gastroenterostomy. 

STERILE   DIET 

The  administration  of  sterile  diet  in  hospital  practice  is  not 
attended  with  special  hardship,  as,  of  course,  the  means  of  sterili- 
zation of  the  articles  of  diet  and  the  containers  is  an  easy  matter. 
In  private  practice  the  problem  presents  some  practical  difficul- 


Fig.  283. — Vessel  for  Administration  of  Sterile  Fluids. 

ties.  Of  course,  chemical  sterilization  of  the  vessels  used  in  pre- 
hension is  impossible,  because  the  antiseptics  are  not  proper  ar- 
ticles of  food.  Sterilization  of  the  vessels  mentioned  must  be 
attained  by  heat.  For  the  purpose  white  enameled  receptacles 
may  be  used,  which  are  boiled.  A  gas  stove  with  two  burners 
should  be  placed  in  the  patient's  immediate  environment,  one  of 
which  furnishes  heat  to  the  large  metal  boiler  in  which  the  re- 
ceptacles are  sterilized  by  boiling  for  twenty  minutes,  and  the 
other  cooks  the  food.  Dry  baking  will,  of  course,  not  sterilize 
the  food,  and  as  liquid  food  is  to  be  partaken  of  for  the  four  days 
preceding  the  operation,  this  outfit  will  be  found  to  serve  the  pur- 
pose. 

Contamination  of  the  vessels  is  liable  when  being  used  for 
transporting  the  nourishment  from  the  boiling  utensil  to  the  pa- 
tient's mouth.  To  avoid  this,  small  vessels  with  handles  should 
be  used,  and  at  no  time  need  the  hand  come  in  contact  with  the 
portion  of  the  vessel  which  must  not  be  contaminated.     Fig.  283 


STERILE   DIET 


431 


shows  a  vessel  which  has  been  found  of  use  in  this  connection, 
which  will  be  found  in  most  households  or  is,  at  least,  obtainable 
in  housefurnishing  stores.  Several  of  these  vessels  may  be  at 
hand  at  a  time. 

After  the  sterilization  by  boiling  is  completed,  the  handle  of 
the  vessel  is  grasped  with  a  sponge  holder  and  so  manipulated  as 
to  be  accessible  to  the  hand  of  the  attendant.  This  had  best  be 
done  after  the  water  has  sufficiently  cooled  to  make  manual  con- 
tact possible.  It  is  unwise  to  expect  the  attendant  to  sterilize  the 
hands  each  time  a  feeding  takes  place.  Again,  if  the  patient  him- 
self is  enabled  to  handle  the  vessel  from  which  the  food  is  taken, 
the  rate  of  administration  of  the  food  is  under  his  own  control, 
which  is  desirable.  The  food  should  be  cooked  and,  of  course, 
at  the  same  time  sterilized  in  a  vessel  which  will  permit  of  the 
liquid  being  poured  into  the  feeding  vessel  without  contamina- 
tion.    Vessels  which  have  handles  are  exceedingly  convenient  for 


Fig.  284. — Arrangement  for  Sterilizing   Food. 


the  purpose  (Fig.  284).  It  should  be  borne  in  mind  that  albu- 
min is  coagulated  by  heat,  and  that  the  nutritive  constituents  of 
the  basis  of  broths  is  not  present  in  liquid  extracts.  There  is  no 
objection  to  the  administration  of  particles  of  macerated  beef 
which  has  been  subjected  to  sterilizing  heat,  for  the  reason  stated, 


432  OPERATIONS  OX  THE  ABDOMEN 

and,  too,  because  the  presence  in  the  stomach  of  firmly  coagu- 
lated albuminoids  ■  stimulates  secretion  of  gastric  juice,  as  has 
been  experimentally  proven  in  many  instances.  If,  as  Cushing 
says,  a  normal  secretion  of  gastric  juice  contributes  much  to  the 
sterility  of  the  gastrointestinal  canal,  the  use  of  this  prepara- 
tion is  advisable.  The  method  of  preparation  consists  of  macer- 
ating fresh,  lean  beef  in  a  mangier,  mixing  it  with  cold  water, 
and,  after  adding  seasoning,  boiling  for  twenty  minutes.  The 
result  is  a  mushy  mess  which  is  readily  swallowed  without  masti- 
cation and  is  quite  palatable.  Indeed,  the  mess  can  be  forced 
through  the  stomach  tube  immediately  after  gastric  lavage  by  a 
syringe  (Fig.  251)  when,  for  any  reason,  the  latter  is  system- 
atically employed  as  a  preliminary  step  to  operation.  The  ad- 
ministration of  the  mixture  may  be  done  once  daily  as  supple- 
mentary to  the  pure  liquid  diet.  Milk  is,  of  course,  readily 
sterilized  by  boiling,  but  the  coating  of  the  fat  globules  with  the 
coagulated  albumin  renders  it  of  less  service  as  a  food,  more  espe- 
cially as  the  digestion  of  fats  takes  place  in  the  small  intestines. 
However,  this  should  not  act  as  a  deterrent  to  its  judicious  use. 
For  the  purpose,  milk  with  a  portion  of  the  cream  removed  had 
best  be  used  for  the  day  before  the  operation.  The  additional 
hardship  to  the  digestive  tract  several  days  before  the  operation 
may  be  regarded  as  counterbalancing  the  objection  stated.  Car- 
bohydrates in  the  form  of  grain  gruels  may  be  sterilized  and 
given  to  within  twenty-four  hours  before  the  operation.  The  fact 
that  carbohydrates  leave  considerable  residue  in  the  intestinal 
canal  after  extraction  of  the  nutritive  constituent  by  the  circula- 
tion explains  the  rationale  of  this  advice. 

The  use  of  table  service,  spoons,  etc.,  had  best  be  dispensed 
with,  and  the  patient  is  ordered  to  partake  of  nourishment  di- 
rectly from  the  vessel  into  which  the  food  has  been  poured.  Boil- 
ing of  the  food  in  the  same  vessel  from  which  it  is  administered 
is  not  desirable,  as  its  upper,  outer  portion  is  subjected  only  to 
dry  heat,  and  is  not  as  certainly  sterilized  as  when  boiled  in  the 
manner  stated.  "Water  is,  of  course,  readily  made  sterile,  and 
may  be  administered  in  the  same  way  as  sterile  food.  It  will  be 
found,  however,  that  but  little  water  will  be  partaken  of  during 
the  administration  of  liquid  food.  Indeed,  the  aim  of  the  latter 
may  be  to  obviate  the  necessity  of  its  use. 


DRAINAGE  433 

DRAINAGE 

Drainage  after  abdominal  operations  has  been  so  extensively 
discussed  in  the  recent  literature  that  protracted  treatment  of  the 
subject  in  this  connection  is  quite  out  of  place. 

Yates,  quoted  by  Moynihan,  says  "  drainage  of  the  general 
peritoneal  cavity  is  physically  and  physiologically  impossible." 
This  is  no  doubt  true.  It  is  to  be  remembered,  however,  that  this 
does  not  dismiss  the  subject  of  drainage  after  abdominal  opera- 
tions, as  the  terse  statement  above  might  lead  one  to  believe. 
There  are  many  instances  in  which  the  abdomen  is  opened  in 
which  drainage  is  distinctly  indicated,  but  these  instances  are 
limited  to  the  class  of  cases  when  egress  is  made  possible  by  fur- 
nishing an  avenue  of  escape  of  inflammatory  exudates  which  are 
situated  immediately  contiguous  to  the  wound  of  entrance,  i.e., 
to  the  drainage  opening.  For  instance,  a  large  peritoneal  ab- 
scess complicating  pyosalpinx  has  for  its  walls  a  thickened  pyo- 
genic membrane  which  it  is  impossible  to  remove  at  the  time  of 
the  operation.  Drainage  under  these  circumstances  is  essential 
to  recovery,  despite  the  fact  that  the  pyosalpinx  itself  may  have 
been  removed  at  the  time  of  the  operation.  A  pericecal  abscess 
complicating  suppurative  appendicitis,  with  sloughing  of  the 
cecum  contiguous  ■  to  the  inflamed  appendix,  will  almost  surely 
be  followed  by  a  fecal  fistula.  Here,  certainly,  is  an  indication 
for  drainage,  but  here,  again,  the  problem  is  not  that  of  drain- 
age of  the  general  peritoneal  cavity.  The  statement  of  Yates  is 
not  damaged  in  the  least  by  the  equal  truth  of  the  examples  of- 
fered, yet  a  casual  perusal  of  it  might  lead  to  an  erroneous  con- 
clusion. The  special  indications  for  drainage  in  a  given  class  of 
cases  will  be  taken  up  under  their  especial  heads.  Yates  also 
states  "  peritoneal  drainage  must  be  local,  and  unless  there  is 
something  to  be  gained  by  rendering  an  area  extraperitoneal,  or 
by  making  such  an  area  a  safe  path  of  least  resistance  leading 
outside  the  body,  there  is,  aside  from  hemastasis  no  justification 
for  its  use,"  which  is  another  way  of  saying  what  has  been  of- 
fered above.  Yet,  this  later  statement  is  at  the  first  glance  so  at 
variance  with  the  one  first  quoted  as  to  perhaps  lead  to  confusion, 
which  an  attempt  has  been  made  here  to  efface. 

The  question  of  drainage  is,  of  course,  determined  at  the  time 


434  OPERATIONS    ON   THE   ABDOMEN 

of  the  operation.  Its  removal  is  frequently  a  question  which  the 
general  practitioner  has  to  determine  as  to  how  soon  the  drain 
may  be  removed.  Nor,  indeed,  is  this  question  always  easy  to 
decide.  Hernia  follows  celiotomy  most  frequently  when  drain- 
age has  been  employed,  yet  it  is  wiser  to  run  the  risk  of  this  com- 
plication than  to  permit  of  the  reaccumulation  of  septic  secre- 
tions, the  result  of  too  early  removal  of  the  drainage  agent.  The 
question  is  also  taken  up  in  connection  with  a  given  class  of  cases 
in  this  regard.  However,  it  may  be  proper  to  state  here  that,  as 
far  as  the  danger  of  invasion  of  the  contiguous  peritoneum  is  con- 
cerned, this  is  obviated  in  twenty-four  hours  following  the  opera- 
tion. The  wound  of  egress,  through  the  abdominal  wall,  need  not 
be  artificially  kept  open  for  more  than  four  days,  at  which  time 
the  septic  secretion  will  be  found  to  have  made  an  avenue  of  escape 
for  itself  along  the  path  of  the  drain,  and  the  secretion  needs  there- 
after be  simply  guided  toward  the  periphery  by  strands  of  silk- 
worm gut,  which  are  gradually  reduced  in  number  until  the  dis- 
charge ceases.  Postural  efforts  at  drainage  are  indicated  in  the 
class  of  cases  mentioned,  though  they  are  of  doubtful  value  when 
general  peritonitis  exists,  i.e.,  a  local  collection  of  pus  will  drain 
better  if  the  patient  be  postured  in  such  a  manner  as  to  make  the 
seat  of  affliction  the  most  dependent  portion  of  the  body.  A  hard 
and  fast  rule  in  this  regard  is  objectionable,  as,  for  instance,  in 
cases  where  the  suppurative  process  is  low  down  in  the  pelvis 
and  abdominal  drainage  is  made,  the  sitting  posture  is  contrain- 
dicated  for  obvious  reasons.  The  drainage  material  employed  in 
this  situation  is  governed  by  the.  same  rules  as  obtain  in  other 
portions  of  the  body  (page  186). 

It  is  the  writer's  practice  to  employ  drainage  in  accord  with 
the  statements  made  above.  A  perhaps  common  source  of  error 
with  respect  to  the  efficiency  of  drainage  and  its  bearing  on  the 
outcome  with  respect  to  recovery,  is  the  fact  that  no  doubt  the 
prognosis  of  general,  or  at  least  widely  spread,  septic  peritonitis 
depends  largely  upon  the  character  of  the  causative  infection.  An 
observer  may  be  led  to  regard  the  measure  as  effective  in  a  series 
of  cases  of  this  sort,  in  which  the  infection  did  not  possess  great 
virulence,  and  the  reverse  may  be  the  case  if  a  series  of  cases  of 
great  virulence  come  under  observation  during  a  short  period  of 
time. 


CLOSURE   OF   THE   ABDOMINAL   WOUND  435 

CLOSURE   OF   THE   ABDOMINAL   WOUND 

Closure  of  the  abdominal  wound  is  universally  made  by  "  tier 
suture."  The  suture  material  employed  for  apposition  of  the 
deep  layers  of  the  abdominal  wall  should  consist  of  absorbable 
suture  material.  The  suggestion  with  regard  to  the  use  of  thick 
catgut  in  deep  wounds,  taken  up  under  the  general  head  of  suture 
material  (page  85),  should  be  borne  in  mind.  Deep  infection  in 
this  situation,  though  comparatively  rare,  does  at  times  occur, 
and  if  the  wound  need  be  opened  with  the  view  of  draining  the 
pus,  ventral  hernia  is  likely  to  occur.  For  the  purpose  of  closing 
the  peritoneum,  ]STo.  1  plain  catgut;  for  the  muscle,  ]STo.  2  chromi- 
cized  gut ;  for  the  rectus  sheath,  ISTo.  1  plain  gut  are  the  sizes  ad- 
vised. The  skin  is  best  closed  with  iron-dyed  silk-worm  gut,  the 
reasons  for  which  have  already  been  stated  (page  97).  The  ra- 
tionale of  using  plain  catgut  of  small  diameter  in  the  rectus 
sheath,  is  that  this  membrane  is  but  sparsely  supplied  with  blood 
and  consequently  does  not  readily  absorb  the  suture  material. 
The  presence  of  chromicized  gut  for  a  prolonged  period  of  time 
favors  infection  and,  indeed,  it  not  infrequently  happens  that  on 
the  tenth  day  or  later,  following  the  operation,  separation  of  a 
slough  of  the  sheath  necessitates  opening  of  the  wound.  The  at- 
tendant is  warned  that  the  employment  of  a  continuous  suture  in 
the  rectus  sheath  which  is  tightly  drawn  and  comprehends  fre- 
quent puncture  of  its  substance  is  a  menace  in  this  connection 
from  strangulation  of  the  edges  of  the  sheath  of  the  muscle.  The 
rectus  sheath  should  be  closed  with  sutures  which  are  placed  only 
sufficiently  closely  together  to  hold  gently  the  edges  of  the  wound 
in  apposition.  In  no  portion  of  the  body  is  the  fallacious  notion 
that  firm  apposition  of  wound  surfaces  is  essential  to  healing 
more  objectionable  than  in  closure  of  an  abdominal  wound. 
Union  by  primary  intention  is  exceedingly  desirable  in  this  situ- 
ation. Aside  from  the  dangers  involved  as  regards  postoperative 
hernia,  as  stated,  the  patient,  who  would  probably  have  been  able 
to  leave  the  bed  in  two  weeks  or  less  following  abdominal  section, 
is  confined  to  bed  for  several  additional  weeks  while  the  healing 
by  granulation  takes  place. 


30 


436  OPERATIONS   ON  THE  ABDOMEN 

DRAINAGE   OF   THE   SUPERFICIAL   WOUND 

Drainage  of  the  superficial  wound  after  celiotomy  has  been 
quite  discarded,  unless,  of  course,  in  the  event  of  the  presence  of 
the  conditions  in  which  drainage  is  introduced  into  the  abdominal 
cavity,  when  the  drain  entering  the  peritoneum  also  answers  the 
purpose  for  the  superficial  wound.  Most  surgeons  entirely  close 
the  superficial  wound  in  clean  cases.  It  is,  however,  rational  to 
make  somewhat  elastic  this  proposition.  Given  a  fat  abdomen 
sectioned  and  the  edges  of  the  wound  subjected  to  prolonged 
trauma,  the  outcome  of  hauling  and  mauling  with  retractors,  or 
the  operator's  hands,  superficial  necrosis  of  the  subcutaneous  fat 
is  very  likely  to  occur  and,  as  nature  attempts  to  throw  the  for- 
eign material  off,  a  purulent  secretion  accumulates  beneath  the 
skin,  which  it  becomes  necessary  to  liberate  by  opening  a  more 
or  less  extensive  portion  of  the  skin  wound.  Again,  a  fat  ab- 
dominal wound  will  ooze  a  peculiar  oily  material  from  the  sub- 
cutaneous tissues,  which  undergoes  much  the  same  alteration 
stated  above.  This  secretion  is  not  arrested  by  the  usual  hemo- 
static measures ;  indeed,  efforts  made  in  this  direction  involve  a 
degree  of  trauma  to  the  tissues  which,  of  itself,  favors  necrosis. 
In  these  cases  a  small  drain,  placed  contiguous  to  the  rectus 
sheath  and  immediately  beneath  the  layer  of  subcutaneous  fat 
and  brought  out  at  the  inferior  angle  of  the  wound,  will  permit 
of  egress  of  the  offending  material  and  favor  primary  union.  The 
skin  plays  no  part  in  retention  of  the  abdominal  contents,  and  the 
slight  delay  in  union  caused  by  the  presence  of  the  drain  need  not 
be  regarded  as  a  disturbing  factor  of  determining  import.  The 
drain  may  consist  of  strands  of  chromic  catgut  or  silk-worm  gut, 
and  is  removed  on  the  third  day  following  the  operation.  At  this 
time  the  gauze  contiguous  to  the  wound  will  be  found  quite  satu- 
rated with  a  glairy  secretion,  slightly  stained  with  blood  which 
has  been  given  an  opportunity  to  escape  from  the  wound  by  em- 
ployment of  the  superficial  drainage. 

THE   PROTECTIVE   DRESSING 

The  protective  dressing  consists  of  two  layers  of  folded  gauze 
(Fig.    187),    which    is    applied    immediately    contiguous    to    the 


THE   PROTECTIVE   DRESSING 


437 


wound,  as  shown  in  Fig.  187.  This  is  supplemented  by  fluffed 
gauze  (Fig.  188),  the  latter  being  applied  in  large  quantity  if 
drainage  has  been  introduced  into  the  peritoneum.  The  fluffed 
gauze  is  covered  with  "combined  dressing"  (Fig.  190),  and  the 
entire  dressing  held  in  place  with  strips  of  adhesive  plaster.  For 
the  purpose  the  strips  are,  in  some  instances,  carried  across  the 
dressing  in  one  piece  and  extend  to  well  on  the  flanks. 

This  has  the  advantage  of  making  firm,  equable  pressure  upon 


Fig.  285. — Abdominal  Dressing  Held  in  Place  With  Adhesive 
Strips  and  Tapes,  Allowing  of  Change  of  Gauze  Pad  With- 
out Removal  of  Adhesive  Plaster. 


the  abdomen,  which  is  desirable  for  the  first  twelve  hours  follow- 
ing the  operation.  However,  at  the  end  of  this  time  distention  of 
the  gut  almost  invariably  occurs,  and  the  pressure   becomes  ex- 


438 


OPERATIONS   ON   THE   ABDOMEN 


ceedingly  distressing  to  the  patient.  The  strips  may  then  be 
loosened,  a  step  which  calls  for  considerable  disturbance.  In 
most  instances  it  is  the  wisest  to  fasten  the  adhesive  plaster  strips 
to  either  flank  and  unite  them  by  means  of  tapes  over  the  dress- 
ing (Fig.  285).  It  will  be  seen  that  it  requires  only  untying  of 
the  tapes  to  effect  the  purpose.  Whatever  pressure  need  be  made 
upon  the   abdomen   can   readily   be    attained   by   means    of   the 


Fig.  286. — Many  Tailed  Abdominal  Binder  in  situ. 


Sculletus  (Fig.  286)  binder,  and  this  can  be  loosened  with 
a  minimum  of  disturbance  to  the  patient  when  the  indication 
arises. 

In  the  absence  of  the  Scultetus  bandage,  a  binder  similar  to 
that  used  after  confinement  may  be  used  (Fig.  287),  which  will 
serve  quite  well  the  purpose.     Two  perineal  straps  should  be  used, 


THE   AFTER-TREATMENT  FOLLOWING   CELIOTOMY        439 


as  this  bandage  is 
more  likely  to  slip  up- 
ward as  the  result  of 
the  patient's  move- 
ments. 


THE  AFTER-TREAT- 
MENT FOLLOWING 
CELIOTOMY 

The  after-treatment 
following  celiotomy 
involves  no  particular 
modification  with  re- 
gard to  shock  and 
narcosis       precautions 

(page    154).      As   SOOn         Fig.  287. — Retaining  Bandage  after  Celiotomy. 

as  these  two  elements  {Bryant.) 

have  been  eliminated, 

the  posture  of  the  patient  depends  upon  the  affliction  for  which  the 

section  has  been  made.     After  operations  upon  the  stomach  and 

following  some  on  the  gall-bladder,  the  sitting  posture  will  be 

found  to  best  conserve  the  patient's  comfort  and  the  intent  of  the 

operative  procedure. 

Postoperative  vomiting  has  been  made  the  text  of  extensive 
discussion  above  (page  272,  et  seq.).  Following  celiotomy  this 
symptom  takes  on  additional  import,  and  attention  is  called  to 
the  necessity  of  avoiding  its  occurrence,  or  at  least  contributing 
to  its  arrest  as  soon  as  possible.  Some  surgeons  wash  out  the  pa- 
tient's stomach  while  he  is  still  on  the  operating  table  and  before 
narcosis  is  recovered  from.  The  measure  has  no  objections  dis- 
cernible to  the  writer  and,  indeed,  may  obviate  distressing  symp- 
toms. Whatever  conception  may  be  had  of  the  measure  regarding 
its  routine  employment  after  operations  in  general,  it  is  a  de- 
sirable indulgence  following  celiotomy  performed  for  conditions 
which  of  themselves  are  accompanied  by  vomiting.  In  the  pres- 
ence of  peritonitis  or  intestinal  obstruction,  the  measure  should 
always  be  employed.  The  fact  that  the  patient  is  still  narcotized 
eliminates,  as  far  as  this  particular  lavage  is  concerned,  the  dis- 


440 


OPERATIONS    ON   THE   ABDOMEN 


tressing  retching  and  vomiting  attendant  upon  gastric  lavage 
made  during  consciousness.  With  the  patient  still  narcotized, 
copious,  prolonged,  and  thorough  lavage  of  the  stomach  may  be 
made  without  bringing  any  strain  upon  the  wound,  which  latter 
is  so  objectionable  when  the  measure  is  employed  during  the  post- 
operative period  following  celiotomy.  At  the  end  of  the  lavage 
no  residual  cleansing  fluid  should  be  permitted  to  remain  in  the 
stomach,  for  fear  of  contributing  to  the  dilatation  of  this  organ, 
which  may  occur  as  a  postoperative  complication.     Acute  dilata- 


Fig.  288. — Acute  Dilatation  of  the  Stomach    Following  Abdominal  Section. 

(Campbell  Thomson.) 


tion  of  the  stomach  sequential  to  celiotomy  is  a  more  frequent 
occurrence  than  obtains  after  operations  involving  other  portions 
of  the  body.  The  problem  has  been  quite  extensively  taken  up 
above  (page  271,  et  seq.).  Allusion  is  made  to  it  in  this  connec- 
tion for  the  reason  stated  with  regard  to  frequency.  Fig.  288 
shows  a  specimen  of  dilated  stomach.  The  illustration  is  placed 
contiguous  to  this  portion  of  the  discussion  to  emphasize  the 
subject. 


THE   AFTER-TREATMENT   FOLLOWING   CELIOTOMY 


441 


It  is  not  improbable  that  routine  lavage  of  the  stomach  fol- 
lowing celiotomy,  especially  if  the  gastro-intestinal  tract  has  been 
invaded,  is  of  service  in  preventing  acute  dilatation  of  this  organ. 

After  the  patient  is  returned  to  bed  and  postured,  as  stated 
above,  in  the  way  to  meet  the  indications,  he  is  not  disturbed  until 
narcosis  is  recovered  from.  Patients  who  have  been  subjected  to 
extensive  operations  or  those  which  have  involved  loss  of  large 
quantities  of  blood,  are  likely  to  be  very  restless.  Of  course,  the 
shock  treatment  is  then  instituted  at  once,  which  implies  close 
attendance.  However,  if  restlessness  follows  from  irritation  of 
nerve  centers  due  to  the  previous  alcoholic  habits  of  the  patient, 
or  as  the  outcome  of  the  subconsciousness  between  narcosis  and 
mental  clearness,  it  may  be  necessary  to  restrain  the  patient  with 
the  view  of  avoiding  damage  to  the  wound,  displacement  of  the 
protective  dressing,  or,  indeed,  to  prevent  the  patient  from  doing 
himself  harm.  For  the  purpose  it  is  best  to  have  in  attendance 
a  cool-headed  nurse.  Failing  in  this,  the  sheet  may  be  fastened 
over  the  patient  in  such  a  way  as  to  prevent  motion  of  the  body, 
and  the  upper  limbs  fastened  to  the  sides  of  the  bed  by  padding 
the  wrists  with  cotton  batting  and  applying  a  bandage  over  this, 


Fig.  289. — Method  of  Restraining  Patient  after  Operation. 


which  is  tied  to  the  side-bar  of  the  bed  (Fig.  289).  The  restraint 
should  be  removed  as  soon  as  quiet  obtains.  The  treatment  of 
shock  has  been  fully  discussed  above  (page  233).     As  soon  as  con- 


442  OPERATIONS    ON   THE   ABDOMEN 

sciousness  returns  and  the  vomiting  is  a  not  marked  symptom, 
the  introduction  of  particles  of  ice  into  the  mouth  is  permitted. 
This  should  be  done  by  an  attendant,  and  the  patient  not  allowed 
to  undergo  the  exertion  necessary  to  self-administration.  The 
use  of  ice  may  be  alternated  by  teaspoonfuls  of  hot  water  given 
at  frequent  intervals,  an  indulgence  which  will  help  relieve  thirst 
and  is  less  often  attended  by  vomiting  than  the  former.  It  is  well 
to  remember  that  deglutition  requires  six  seconds  from  the  lips 
to  the  stomach,  and  that  a  small  dose  of  hot  water  trickles  very 
slowly  along  the  esophagus  and  is  not  apt  to  contribute  an  im- 
portant factor  to  the  causation  of  dilatation  of  the  stomach. 

Thirst,  which  is  the  most  constantly  distressing  symptom  fol- 
lowing celiotomy,  may  be  relieved  by  the  rectal  administration  of 
saline  water  (page  283). 

As  a  routine,  the  writer  orders  a  saline  enema  given  in  cases 
following  celiotomy  of  500  c.c.  of  a  normal  salt  solution  placed  in 
the  rectum  every  six  hours.  The  first  injection  is  made  soon  after 
the  patient  is  in  bed.  This  is  not  intended  to  relieve  shock.  If 
the  latter  be  a  factor  in  the  case,  the  treatment  is  carried  out  as 
stated  (page  233).  It  would  seem  that  the  measure  controls 
thirst  to  some  extent.  The  quantity  of  saline  solution  injected 
should  never  be  sufficient  to  cause  the  lower  bowel  to  rebel  and 
expel  it.  Of  course,  larger  quantities  are  most  generally  tolerated 
in  this  situation.  However,  this  is  probably  only  so  when  the 
tube  is  inserted  high  up  into  the  bowel,  a  procedure  which  should 
be  reserved  for  especial  indications. 

If  vomiting  persist  after  celiotomy,  attempts  at  the  administra- 
tion of  food  by  the  mouth  had  best  be  entirely  abandoned  and 
rectal  alimentation  (page  291)  given  exclusively  until  vomiting 
ceases.  Vomiting  persisting  into  the  second  twenty-four  hours 
following  the  operation  should  arouse  suspicion  of  nephritis.  If 
this  be  found  to  be  the  case,  the  usual  treatment  directed  toward 
using  the  vicarious  channels  of  elimination,  i.e.,  the  skin  and 
bowel,  should  be  vigorously  employed. 

Nephritis  following  celiotomy  occurs  as  the  result  of  adminis- 
tration of  ether  and  perhaps,  too,  owing  to  the  congested  condition 
of  the  splanchnic  area  from  shock.  It  is  not  of  necessity  a  seri- 
ously menacing  condition  if  recognized  early  and  made  the  sub- 
ject of  therapeutic  attack.     The  administration  of  morphia  in 


THE  AFTER-TREATMENT   FOLLOWING   CELIOTOMY         443 

considerable  quantity  during  the  nephritis  is  contraindicated, 
though  it  must  be  borne  in  mind  that,  if  pain  be  a  factor  in  the 
case,  its  use  may  not  be  avoidable,  and  the  attendant  must  use 
his  best  judgment  in  the  individual  case  as  to  the  dosage.  It  will 
be  found  difficult  to  withhold  the  drug  entirely  in  some  instances. 

The  quantity  of  urine  excreted  after  celiotomy  is  usually 
small  as  the  result  of  vomiting  and  the  fact  that  the  taking  of 
food  has  been  abstained  from  for  several  hours  before  the  opera- 
tion, together  with  the  loss  of  blood  attendant  upon  the  surgical 
manipulations.  If  no  fluid  is  introduced  into  the  circulation  soon 
after  the  operation  the  convoluted  tubes  of  the  kidney,  theoretic- 
ally, at  least,  should  be  engorged  with  solid  excretory  constitu- 
ents. This  condition  of  affairs,  while  not  readily  conceived  of  as 
of  determining  influence  upon  nephritis, .  is  sufficiently  objection- 
able to  warrant  attempts  at  furnishing  the  blood  with  fluid.  At 
the  end  of  twenty-four  hours  considerable  quantities  of  fluid 
should  be  given  by  the  mouth,  provided  vomiting  has  ceased. 

Retention  of  urine  after  celiotomy  is  a  common  occurrence. 
Catheterization  should  not,  however,  be  indiscriminately  em- 
ployed. The  nurse  is  instructed  to  cause  the  patient  to  attempt 
to  pass  spontaneously  the  urine  at  the  end  of  six  hours  following 
return  to  the  bed.  If  the  effort  be  unsuccessful,  an  attempt  should 
be  made  every  two  hours  and  a  total  of  twelve  hours  be  allowed 
to  elapse  before  the  catheter  is  used.  A  record  of  the  total  quan- 
tity of  urine  excreted  in  twenty-four  hours  should  be  kept,  with 
the  view  of  standardizing  the  quantity  of  fluids  administered. 
The  patient's  sensations  with  regard  to  the  necessity  for  fluid  is 
not  always  a  reliable  guide  in  this  connection,  as  the  administra- 
tion of  ojnates  may  impair  the  sensorium.  The  catheterization 
must,  of  course,  be  executed  under  aseptic  precautions.  The 
catheter  should  be  sterilized  by  boiling  and  kept  in  a  vessel  sub- 
merged in  mild  carbolic  acid  solution,  in  a  convenient  place.  The 
meatus  and  contiguous  parts  should  be  gently  wiped  with  a  sterile 
gauze  sponge,  soaked  with  the  same  solution  before  the  catheter 
is  introduced.  A  chemical  examination  of  the  urine  should  be 
made  every  twenty-four  hours  for  several  days  following  the 
operation. 

The  administration  of  opiates  may  be  stated  as  objectionable  in 
principle,  but  necessary  in  a  certain  number  of  cases.     The  ob- 


444  OPERATIONS    ON   THE   ABDOMEN 

jections  are  that  they  paralyze  peristalsis,  which  favors  the  forma- 
tion of  adhesions,  that  they  lessen  secretions  and  excretions,  of 
which  the  latter  is  the  most  important  factor,  and  that  they  mask 
symptoms  which  are  indicative  of  complications.  On  the  other 
hand,  arrest  of  peristalsis  is  not  objectionable  for  twenty-four 
hours  after  invasion  of  the  lumen  of  the  digestive  tract,  as  it  is 
easy  to  see  that  a  wiggling  gut  will  not  heal  as  certainly  as  one 
which  is  immobilized.  This  is  a  principle  with  regard  to  repair 
of  all  tissues  in  all  parts  of  the  body.  Again,  pain  which  is  suffi- 
ciently severe  to  cause  restlessness  and  interfere  with  the  exercise 
of  the  necessary  after-treatment  is  best  controlled,  even  if  the  ob- 
jectionable features  of  the  opiate  have  to  be  taken  into  account. 
Opiates  are  more  readily  avoided  in  cases  which  do  not  involve 
much  intra-abdominal  manipulation,  i.e.,  a  ventral  uterine  fixa- 
tion will  not  be  followed  by  severe  pain  and  an  opiate  need  not 
be  given.  However,  if  there  has  been  much  trauma  to  the  ab- 
dominal organs,  pain  may  be  a  disturbing  factor,  and  the  use  of 
an  opiate  be  unavoidable. 

Catharsis  after  celiotomy  is  employed  early  if  the  lumen  of  the 
digestive  tract  has  not  been  invaded.  Theoretically  stimulation 
of  peristalsis  should  tend  to  prevent  the  formation  of  adhesions. 
It  must  be  remembered  that  the  bowel  has  been  quite  thoroughly 
cleansed  while  the  patient  was  being  prepared  for  the  operation, 
and  that,  aside  from  the  fact  that  the  intestinal  canal  is  to  be  re- 
garded as  an  important  eliminative  organ,  catharsis  is  not  urgently 
indicated.  However,  it  is  not  improbable  that  a  certain  amount 
of  decomposition  of  the  intestinal  contents  takes  place  after  celi- 
otomy, the  outcome  of  a  relative  intestinal  paresis,  and  this  re- 
sults in  the  formation  of  gases  which  distend  the  gut  and  give  rise 
to  distress.  It  is  the  practice  of  the  writer  to  administer  in  these 
cases  one-tenth  of  a  grain  of  calomel  every  half  hour  for  twelve 
doses  beginning  the  second  day  following  the  operation.  When 
twelve  doses  have  been  given,  three  hours  are  allowed  to  elapse, 
and  then  a  saturated  solution  of  magnesium  sulphate  is  given  in 
doses  of  one  drachm,  for  eight  hours,  unless  catharsis  is  provoked 
before  the  entire  half  ounce  of  magnesium  sulphate  is  adminis- 
tered. (Magnesium  sulphate  solutions  saturate  at  50  per  cent.) 
In  this  event  the  administration  of  the  magnesium  sulphate  is 
stopped  when  a  movement  of  the  bowels  occurs.     If  no  discharge 


THE   AFTER-TREATMENT   FOLLOWING   CELIOTOMY  445 

of  feces  occurs  after  the  entire  half  ounce  of  magnesium  sulphate 
is  taken,  two  hours  are  allowed  to  elapse  and  an  enema  of  hot 
water  is  given. 

Tympanitis  after  celiotomy  is  a  common  occurrence.  It  will 
he  found  that  the  measure  stated  above  will  have  a  tendency  to 
control  this  occurrence.  It  is  generally  regarded  as  the  outcome 
of  intestinal  paresis  due  to  handling  of  the  gut.  It,  of  course,  fol- 
lows most  frequently  after  abdominal  operations  involving  the 
lumen  of  the  gut  itself,  but  does  occur  quite  commonly  when  or- 
gans other  than  the  gut  are  attacked.  Especially  is  this  true  if 
it  has  been  necessary  to  pack  off  large  areas  of  the  abdominal 
cavity  with  gauze,  which  packing  is  left  in  situ  for  a  long  period 
of  time.  Perhaps  the  most  important  causative  factor  in  these 
cases  is  intestinal  paresis,  and  treatment  directed  toward  relief 
should  contemplate  correction  of  this  condition  of  affairs.  As 
already  stated,  the  food  administered  immediately  subsequent  to 
celiotomy  is  of  such  a  character  as  to  involve  little  justification 
for  the  belief  that  it  may  be  regarded  as  a  determining  factor  in 
the  problem.  When  distention  occurs  alimentation  by  the  mouth 
should  be  restricted  to  water  given  in  small  closes  and  stimulation 
administered  hypodermically  or  by  rectum,  if  the  indications  for 
the  same  be  presented.  Strychnia  in  doses  of  one-thirtieth  of  a 
grain  given  under  the  skin  at  intervals  of  two  or  three  hours,  if 
not  really  of  service  as  regards  the  relief  from  shock,  serves  the 
purpose  of  stimulating  intestinal  peristalsis.  Doses  of  eserin  of 
one-thirtieth  of  a  grain,  or,  indeed,  of  one-fifteenth  of  a  grain  ad- 
ministered every  two  hours  is  a  most  effective  agent  in  this  con- 
nection, stimulating  peristalsis  and  contraction  of  blood-vessels, 
thus  aiding  in  raising  blood  pressure.  If  the  distention  be  in  the 
colon  the  introduction  of  a  rectal  tube  of  large  caliber  will  afford 
considerable  relief  in  a  number  of  instances. 

Atropin  has  been  largely  employed  for  the  purpose,  given  in 
doses  as  high  as  one-tenth  and  even  one-fifth  of  a  grain.  The 
writer  has  seen  instances  when  this  agent  appears  to  have  been 
successful  in  stimulating  intestinal  peristalsis,  where  oilier  reme- 
dies have  failed.  It  should,  of  course,  not  be  expected  to  replace 
the  mechanical  means  mentioned,  but  may  be  employed  supple- 
mentary to  them.  It  will  probably  be  necessary  to  tie  the  patient 
down  in  bed  after  a  maximum  dose  has  been  given,  as  delirium 


446  OPERATIONS   ON  THE  ABDOMEN 

of  maniacal  quality  is  likely  to  occur.  The  atropin  is  adminis- 
tered hypodermically.  The  doses  may  be  repeated  in  three  hours. 
The  writer  has  never  felt  justified  in  the  administration  of  a 
third  dose.  It  is,  of  course,  to  be  borne  in  mind  that  the  condi- 
tions present  a  desperately  dangerous  clinical  aspect,  and  a  meas- 
ure which,  under  ordinary  circumstances,  is  regarded  as  unjusti- 
fiable may  become  warranted  under  the  circumstances.  The  ap- 
plication of  turpentine  stupes  to  the  abdomen  would  seem  to  be 
of  little  service,  for  obvious  reasons.  The  heat  which  the  appli- 
cation develops  may  be  of  service  in  a  general  way,  but  this  can 
be  attained  by  other  means  which  do  not  expose  the  patient  to  the 
irritating  local  effect  which  attends  the  application  of  turpentine 
to  the  skin.  The  retention  bandage  should  be  loosened  at  once 
and  the  question  of  acute  dilatation  of  the  stomach  borne  in  mind. 
If  relief  is  not  quite  promptly  afforded,  the  stomach  should  be 
washed  out.  The  special  reasons  for  the  latter  measure  have  al- 
ready been  taken  up. 

The  administration  of  agents  designed  to  "  settle  the  stomach  " 
and  remove  gas  is  to  be  deprecated.  The  intestinal  tract  is  in  no 
condition  to  accept  additional  labor.  The  indication  is  clear,  i.e., 
to  stimulate  peristalsis  and  to  remove  by  mechanical  means  the 
gas.  Lavage  of  the  colon  with  saline  solution  if  ample  provision 
for  egress  of  the  fluid  is  made  is  justifiable,  as  it  may  stimulate 
contraction  of  the  gut.  Distention  of  the  gut,  the  outcome  of  in- 
testinal paresis,  is  differentiated  from  that  caused  by  peritonitis 
by  the  absence  of  the  signs  of  inflammation  attendant  upon  the 
latter.  The  differential  diagnosis  will  decide  quite  definitely  the 
question  of  reopening  the  wound,  which  question  may  arise  in 
connection  with  inflammatory  processes  of  the  peritoneum  follow- 
ing celiotomy.  If  the  intestinal  paresis  be  due  to  handling  of  the 
gut,  an  additional  trauma  will  only  add  to  the  condition  pre- 
sented. 

The  administration  of  solid  food  following  celiotomy  should 
not  be  begun  until  there  has  been  a  normal  evening  temperature 
for  three  days.  In  cases  which  run  an  uncomplicated  course  the 
lighter  articles  of  diet,  such  as  chicken,  squab,  and  broiled  meat, 
may  be  given  on  the  fifth  day.  A  free  evacuation  of  the  bowels 
should  precede  the  return  to  usual  articles  of  diet.  In  cases  in 
which  the  digestive  tract  has  been  invaded,  solid  food  should  not 


THE  AFTER-TREATMENT   FOLLOWING   CELIOTOMY         447 

be  given  for  ten  days  after  the  operation,  despite  the  immediate 
favorable  behavior  of  the  case.  Sufficient  fluid  or  light  diet  may 
be  given  to  sustain  the  general  tone  of  the  patient  to  obviate  any 
hardship  in  this  regard.  In  a  general  way,  it  may  be  said  that 
less  error  will  arise,  if  the  precautions  be  carefully  followed  than 
if  a  policy  of  complacency  be  indulged  in. 

The  time  of  leaving  the  bed  in  cases  where  the  abdomen  has 
been  opened  for  any  purpose  should  not  be  less  than  ten  days  fol- 
lowing the  operation.  Much  has  been  written  in  the  current  liter- 
ature with  respect  to  the  early  arising  of  patients  after  celiotomy. 
Some  observers  strap  the  abdomen  very  firmly  after  celiotomy 
with  strips  of  adhesive  plaster  and  permit  the  patient  to  get  out 
of  bed  twenty-four  or  forty-eight  hours  after  the  operation.  Re- 
membrance of  the  complications  which  are  likely  to  follow  in- 
vasion of  the  abdominal  cavity  should  be  sufficient  argument  to 
show  the  fallacy  of  this  procedure.  It  may  be  said  quite  em- 
phatically that  no  repair  of  tissue  is  enhanced  by  motility,  and 
that  immobilization  of  parts  subjected  to  trauma  is  an  almost  in- 
dispensable adjunct  to  repair,  a  lesson  in  nature  one  might  well 
learn  from  the  lower  animals.  In  addition  to  this,  the  histology 
of  the  repair  of  tissue  which  has  been  sectioned  will  teach  the 
rationale  of  the  writer's  contention.  Any  condition  requiring  in- 
vasion of  the  abdominal  cavity  is  worth  the  hardship  of  quiet  in 
bed  for  ten  days  to  two  weeks  following  the  operation.  Those 
conditions  which  would  seem  to  permit  of  disregard  of  this  rule 
probably  did  not  require  operative  interference.  In  no  case,  in- 
cluding interval  intermuscular  appendectomy,  should  a  patient 
subjected  to  celiotomy  be  permitted  to  assume  the  erect  position 
for  ten  days  following  the  section.  And  in  all  cases  where  the 
rectus  is  sectioned  two  weeks  in  bed  should  be  the  rule.  Much 
unnecessary  distress  and,  indeed,  much  adverse  criticism  of  the 
science  of  surgery  will  be  obviated  if  this  is  a  common  practice. 

If  primary  union  does  not  occur  and  the  abdominal  wound 
heal  by  granulation,  the  patient  should  be  kept  in  the  recumbent 
or  semi-recumbent  position  until  firm  union  of  the  muscular  layer 
of  the  abdomen  is  attained.  This  requires  several  weeks  in  some 
instances.  As  soon,  however,  as  the  muscles  are  healed  the  pa- 
tient may  be  permitted  to  leave  the  bed,  even  though  complete 
cicatrization  of  the  skin  has  not  taken  place.     This  is  justified  by 


448 


OPERATIONS   ON   THE   ABDOMEN 


the  fact  that  the  skin  plays  no  part  in  retention  of  the  abdominal 
contents. 

When  the  patient  is  permitted  to  sit  up  or  walk  about,  the  ab- 
domen should  be  firmly  supported  with  an  abdominal  binder 
which  is  applied  while  the  patient  is  still  in  the  recumbent  posi- 
tion, and  the  binder  should  be  fastened  from  below  upward.     The 


Fig.  290. — Granulating  Wound  Ready  for  Secondary  Suturing. 


wearing  of  belts  and  corsets  following  celiotomy  is  taken  up  under 
a  separate  head  (page  475). 

The  removal  of  sutures  after  celiotomy  depends  upon  the  ques- 
tion of  drainage  and  infection.  In  cases  in  which  the  wound  has 
been  closed  up  entirely,  the  sutures  are  left  in  situ  until  the  tenth 
day.  Of  course,  when  catgut  has  been  used,  the  sutures  need  not 
Be  removed  unless  the  portion  of  the  suture  material  buried  be- 
neath the  skin  is  not  absorbed  at  the  end  of  the  ten  days.     The  use 


THE   AFTER-TREATMENT  FOLLOWING   CELIOTOMY         449 

of  catgut  in  the  skin  is,  as  already  stated,  inadvisable  and,  indeed, 
but  little  employed.  The  silk-worm  gut  sutures  are  removed  on 
the  tenth  day,  provided  there  be  no  indication  for  their  earlier 
removal.  In  many  instances  it  will  be  found  possible  to  leave  en- 
tirely undisturbed  the  celiotomy  wound  until  the  time  for  remov- 
ing the  sutures  arrives.  The  method  of  removal  of  sutures  is  al- 
ready described  (page  304,  et  seq.).  If  there  be  infection  of  the 
superficial  wound,  it  should  be  treated  in  the  manner  already  de- 
scribed with  respect  to  other  situations  of  the  body  (page  305). 
If  infection  of  the  superficial  wound  occurs  after  celiotomy, 


Fig.  291. — Granulating  Celiotomy  Wound  Approximated  with  Adhesive  Plas- 
ter Strips.     Rubber  Tissue  Drain  in  situ. 

healing  by  granulation  is  an  exceedingly  tedious  process,  requir- 
ing change  of  dressings  every  forty-eight  hours  for  several  weeks. 
The  scar  following  healing  by  granulation  in  this  situation  is  of 
minor  import  in  the  male,  but  in  certain  cases  the  female  patient 
objects  strongly  to  the  destruction  of  a  certain  cosmetic  effect  pro- 
duced by  a  marred  abdomen.  In  these  instances  the  wound  should 
be  treated  by  cleansing  and  light  packing  until  it  is  clean,  and 
it  may  then  be  quite  approximated  by  deep  silk-worm  gut  su- 
tures, which  do  not  entirely  approximate  the  lower  angle  of  the 
wound.     Fig.  290  shows  a  wound  which  cleaned  up  after  three 


450  OPERATIONS  ON  THE  ABDOMEN 

weeks  of  care,  and  now  presents  a  condition  favorable  to  second- 
ary approximation. 

The  patient  at  times  objects  to  narcosis  and,  indeed,  to  the  in- 
jection of  cocain  solution.  The  latter  is  efficient  for  the  purpose, 
the  injection  of  a  1  per  cent,  cocain  solution  along  the  edges  of  the 
wound  being  quite  devoid  of  pain.  However,  in  some  instances  the 
manipulation  is  strongly  objected  to.  In  these  cases  the  wound 
may,  when  the  purulent  discharge  has  quite  ceased,  be  approxi- 
mated with  adhesive  plaster,  as  shown  in  Fig.  291,  care  being 
taken  to  give  room  for  egress  of  serum  at  the  lower  portion  of  the 
wound.  ISTeglect  of  the  latter  precaution  at  times  gives  rise  to  an 
annoying  dermatitis  in  the  vicinity  of  the  wound.  Wounds  which 
have  been  secondarily  approximated  in  the  manner  stated  at  times 
heal  with  astonishing  rapidity,  and  the  residual  scar  is  not  of 
much  greater  breadth  than  obtains  after  primary  union.  The 
amount  of  time  saved  the  patient  by  the  little  procedure  is  also 
a  factor  to  be  taken  into  consideration. 


CHAPTEE    XXII 

OPERATIONS    ON   THE    ABDOMEN    (Continued) 

PEEITONITIS    FOLLOWING    CELIOTOMY 

Prevention  of  peritonitis  :  Flushing  of  the  peritoneum — Treatment  of  peritonitis  : 
The  Murphy  Treatment. 

PREVENTION   OF   PERITONITIS 

Consideration  of  the  preparation  of  patients  for  celiotomy  who 
are  afflicted  with  intra-abdominal  conditions  which  render  the  oc- 
currence of  postoperative  diffuse  suppurative  peritonitis  a  likely 
complication,  brings  up  the  question  of  prophylactic  measures  be- 
yond those  involved  in  the  operative  technic.  As  a  general  rule, 
it  may  be  said  that  the  accidental  introduction  of  infection  into 
the  peritoneal  sac,  as  the  outcome  of  the  surgical  manipulations, 
per  se,  is  avoidable  by  close  application  to  the  rules  of  asepsis, 
and  special  measures,  such  as  are  about  to  be  discussed,  need  not 
be  considered  in  cases  which  are  operated  upon  for  the  relief  of 
non-infective  processes.  Indeed,  it  would  seem  that  whatever  ex- 
perimental data  is  available  in  this  regard,  is  of  such  a  nature  as 
to  place  the  routine  employment  of  systemic  preparation  with  the 
view  of  lessening  the  probability  of  postoperative  peritonitis  in 
an  objectionable  light. 

However,  given  a  case  of  acute  suppurative  pyosalpingitis, 
acute  suppurative  cholecystitis  or  acute  appendicitis  with  little  or 
no  evidence  of  peritoneal  involvement  and  yet  evidence  of  the  pres- 
ence of  a  virulent  infective  process  in  the  situations  mentioned, 
for  the  relief  of  which  transperitoneal  approach  is  to  be  made,  it 
may  be  justifiable  to  make  an  effort  to  prepare  more  thoroughly 
the  tissues  for  the  contingencies  involved  in  peritoneal  infection. 
If  invasion  of  the  digestive  tract  is  contemplated,  the  measure  to 
31  451 


452  PERITONITIS   FOLLOWING   CELIOTOMY 

be  discussed  should  also  be  taken  into  consideration  in  those  cases 
where  an  operation  of  magnitude  is  to  be  undertaken,  such  as  par- 
tial resection  of  the  stomach,  resection  of  large  portions  of  the  in- 
testine, or  for  the  relief  of  intestinal  obstruction,  where  adequate 
preparation  in  other  regards  is  not  feasible  because  of  the  urgency 
of  the  indications  for  operation.  The  disease  itself,  that  of  acute 
suppurative  peritonitis,  is  a  universally  fatal  affliction,  though, 
indeed,  many  factors  are  to  be  considered  in  a  given  case,  such  as 
the  character  of  the  infection,  etc.,  before  a  definite  conclusion  as 
to  prognosis  in  a  given  case  can  be  justly  offered.  The  measures 
about  to  be  discussed  are  not  by  any  means  in  a  position  to  be 
definitely  offered  as  advisably  used  in  any  given  class  of  cases. 
However,  it  would  seem  wise  to  suggest  that  they  be  given  serious 
consideration  in  the  class  of  cases  alluded  to. 

Much  experimentation  has  been  carried  on  with  the  view  of 
lessening  the  danger  of  postoperative  peritonitis  following  ab- 
dominal section.  It  has  been  observed  that  the  injection  of  vari- 
ous albumoses  into  rabbits  produced  at  first  a  hypoleukocytosis  and 
later  a  hyperleukocytosis.  When  animals  thus  injected  were  in- 
fected with  various  bacteria  during  hypoleukocytosis  they  died, 
but  if  the  injection  of  pathogenic  organisms  was  made  during 
hyperleukocytosis,  sufficient  resistance  was  maintained  to  make  re- 
covery possible.  The  bactericidal  value  of  normal  blood  was  al- 
ways greatest  during  increased  leukocytosis.  These  favorable  con- 
ditions were  produced  as  the  result  of  the  injection  of  nucleins 
into  the  blood  and,  indeed,  an  increase  of  leukocytosis  follows  the 
ingestion  of  nucleins  by  mouth. 

Mickulicz  states : 

The  question  arises  whether  artificial  hyperleukocytosis  may  not 
be  of  value  in  practice  as  a  prophylactic.  According  to  the  experiments 
of  Loewy  and  Richter,  or  Jakob  and  Hahn,  one  cannot  exclude  the 
possibility  that,  by  a  partly  anticipated  mobilization  of  great  masses 
of  leukocytes,  the  latter  may  overcome  the  bacteria  which  had  obtained 
entrance  in  the  first  instance  in  relatively  small  masses  with  greater 
ease,  than  if  the  leukocytes  delay  their  attack  in  force,  until  the  number 
and  virulence  of  the  bacteria  in  the  tissues  have  markedly  increased. 

Experimentation  carried  on  by  Miyake  under  the  directorate 
of  Mikulicz  seems  to  prove  that  the  injection  of  nuclein  in  ani- 


PREVENTION   OF   PERITONITIS  453 

mals  prior  to  the  fertilization  of  the  peritoneal  cavity  by  organ- 
isms had  an  undoubted  effect  in  lessening  the  occurrence  of  peri- 
tonitis.    These  experiments  are  summarized  as 

Consisting  in  performing  a  laparotomy  and  forcing  through  an 
opening  in  the  stomach  or  intestine  as  much  of  their  contents  as  could 
be  obtained  from  the  immediate  neighborhood  of  the  incision.  Of 
five  control  animals  which  had  not  been  previously  prepared,  four 
died  from  peritonitis  between  five  and  sixteen  hours  after  the  opera- 
tion. The  fifth  became  extremely  ill  but  finally  recovered,  but  the 
amount  of  intestinal  contents  which  was  transferred  to  the  perito- 
neum was  less  in  this  case  than  in  the  others.  Ten  animals  were 
prepared.  These  recovered  without  exception.  The  preparation  con- 
sisted of  three  intraperitoneal  injections  of  nucleic  acid,  two  injections 
of  neutralized  nucleic  acid.  In  each  case  laparotomy  was  performed 
seven  hours  after  the  injection.  These  experiments  are  such  as  to 
excite  our  interest  in  the  highest  degree,  for  by  subcutaneous  injection 
of  nucleic  acid,  it  was  possible  to  raise  the  resistance  of  the  peritoneum 
to  such  an  extent  that  even  a  considerable  quantity  of  intestinal  con- 
tents could  be  placed  in  the  peritoneal  cavity  without  causing 
damage,  whilst  without  previous  treatment  an  acute,  rapidly  fatal 
peritonitis  followed  almost  without  exception.  This  opens  out  a  new 
field  for  the  surgeon  in  preventing  postoperative  peritonitis. 

With  regard  to  the  application  of  the  results  of  these  experi- 
ments Mikulicz  states : 

The  number  of  my  experiments  is  not  sufficient  to  permit  me  to 
form  a  definite  judgment  upon  these  points  and  to  give  an  unguarded 
reply.  We  cannot,  in  the  case  of  man,  as  we  do  in  that  of  the  lower 
animals  when  introducing  infective  material  into  the  abdominal 
cavity,  give  a  certain  multiple  of  the  minimum  lethal  dose  in  order 
to  see  how  far  a  preventive  treatment  has  succeeded.  We  set  all  our 
apparatus  in  action,  in  spite  of  preventive  inoculation,  to  reduce  in- 
fection to  a  minimum.  Since  this  method  fortunately  succeeds  in 
the  majority  of  cases,  even  without  preventive  inoculation,  in  guard- 
ing the  patients  from  a  fatal  peritonitis,  a  small  number  of  satisfac- 
tory results  do  not  prove  much ;  but,  on  the  other  hand,  one  or  two 
unsatisfactory  results  most  certainly  cannot  condemn  the  method,  for 
this  method  gives  not  absolute  certainty  like  a  specific  immunization, 
but  only  increases  the  natural  resistance,  and  this  may,  in  certain 
circumstances,  even  when  increased  thirty-fold,  nevertheless  be  insuf- 


454  PERITONITIS    FOLLOWING    CELISTOMY 

ficient.  I  have,  however,  the  impression  that  the  eases  hitherto  treated 
have  given  more  favorable  results,  not  only  in  the  number  of  cases 
recovered,  but.  also,  in  the  progress  of  the  individual  cases,  than  the 
analogous  cases  of  earlier  date  where  the  operation  was  performed 
without  this  preparation.  In  10  cases  of  resection  of  the  stomach  for 
carcinoma,  9  recovered,  6  of  them  without  the  slightest  complication. 
The  progress  was  marked  by  a  smoothness  that  was  quite  exceptional 
before  the  treatment  was  adopted.  Two  cases  which  presented  excep- 
tional difficulty  in  the  removal  of  the  carcinoma  did,  undoubtedly, 
within  twenty-four  hours  develop  peritonitis,  with  a  pulse  up  to  160, 
which  according  to  our  usual  experience,  foretold  the  most  dismal 
prognosis.  The  patients  fortunately  survived  the  peritonitis.  In 
the  ninth  case  which  recovered,  the  progress  was  disturbed  from  the 
fourth  day  by  bronchopneumonia.  The  tenth  case  died;  after  seven 
days  of  uninterrupted  progress,  he  developed  pneumonia,  to  which 
he  succumbed  three  weeks  after  the  operation.  Of  the  remaining 
operations,  I  should  like  to  refer  to  22  cases  of  gastroenterostomy 
and  enteroanastomosis,  12  of  which  were  for  carcinoma.  Of  these 
cases,  19  recovered  and  3  died.  In  all  3  cases  death  was  most  cer- 
tainly not  due  to  peritonitis,  but  in  1  case  to  perforation  of  an  ulcerat- 
ing carcinoma  of  the  stomach  two  weeks  after  the  operation;  in  an- 
other case,  to  continued  hemorrhage  from  a  carcinoma  of  the  stomach 
sixteen  days  after  operation;  and  in  the  third,  to  peritonitis  arising 
from  a  tuberculous  granuloma  in  the  intestine  four  weeks  after  opera- 
tion. Of  6  cases  of  resection  of  the  intestine  at  one  operation,  4 
recovered  and  2  died.  In  one  case  death  occurred  from  collapse  on 
the  second  day  after  a  very  prolonged  operation  of  double  resection 
for  carcinoma ;  in  the  other  case,  where  the  injury  was  a  bullet  wound, 
death  took  place  on  the  tenth  clay  from  hemorrhage  from  the  vena 
cava.  In  neither  of  the  cases  was  there  any  peritonitis.  One  case 
of  opening  the  stomach  and  stretching  the  cardiac  orifice,  performed 
on  account  of  spasm,  recovered.  So  also  did  6  cases  of  operation  on 
the  bile  duct,  7  other  operations  upon  abdominal  organs  without  open- 
ing the  intestinal  tract,  and  3  extra-abdominal  operations.  The  last 
to  be  mentioned  are  2  cases  of  nephrectomy,  which  were  treated  before 
the  operation  with  nucleic  acid.  In  both  cases,  in  order  to  remove 
the  suppurating  kidney,  the  peritoneum  had  to  be  widely  opened. 
One  case  recovered,  the  other  died  twelve  days  after  the  operation 
from  hemorrhage  from  the  renal  artery.  In  this  case,  too,  there  was 
no  peritonitis.  We  therefore  have  45  laparotomies  in  which  the  ab- 
dominal cavity  was  exposed  to  infection  by  the  contents  of  the  stomach 
or  intestines  or  bv  some  other  infectious  secretion;  38  of  these  cases 


FLUSHING   OF   THE   PERITONEUM  455 

recovered,  and  in  none  of  the  7  fatal  results  was  peritonitis  the  cause 
of  death. 

Mikulicz  has  finally  settled  upon  injecting  50  c.c.  of  neutral- 
ized nucleic  acid,  2  per  cent.,  twelve  hours  hefore  the  operation. 

FLUSHING  OF  THE  PERITONEUM 

Flushing  of  the  peritoneum  with  large  quantities  of  saline 
solution  and  permitting  a  moderate  amount  to  remain  in  situ 
after  completion  of  the  intra-abdominal  operation  is  a  practice 
quite  largely  employed  by  surgeons.  It  is  probable  that  the  re- 
sistance of  the  peritoneum  to  infection  is  increased  by  this  means. 
It  is  wise  to  omit  the  measure,  in  the  presence  of  considerable 
quantities  of  purulent  secretion  not  widely  distributed,  for  fear 
of  spreading  mechanically  the  infection.  The  most  rational  field 
of  usefulness  of  the  measure  would  seem  to  be  in  cases  where  the 
peritoneum  has  been  subjected  to  considerable  trauma  for  the  re- 
lief of  non-infective  afflictions,  such  as  carcinoma  of  the  uterus  or 
other  neoplasms  in  this  situation.  The  solution  should  have  a 
temperature  of  110°  F.,  and  be  poured  into  the  wound  by  means 
of  a  pitcher.  About  500  c.c.  of  the  solution  is  comfortably  taken 
care  of  by  the  peritoneum  in  twelve  hours. 

The  writer  usually  employs  flushing  after  hysterectomy  or 
transperitoneal  nephrectomy,  but  omits  it  when  the  intestinal 
canal  has  been  opened  either  with  the  view  of  relieving  affliction 
or  accidentally  while  operating  upon  contiguous  organs.  When- 
ever hemorrhage  has  been  a  factor  in  the  procedure,  the  flushing 
is  maintained  until  the  solution  returns  clear,  and  then  500  c.c. 
of  the  fluid  is  left  in  situ.  Under  these  conditions  employment  of 
the  measure  seems  advisable.  Peritonitis,  of  course,  does  not  fre- 
quently follow  this  class  of  cases,  and  a  standard  as  to  its  efficiency 
with  respect  to  obviating  its  occurrence  is  not  possible. 

Kader  uses  an  antistreptococcic  serum  with  the  view  of  im- 
munizing the  patient  against  peritonitis.  While  the  measure  has 
not  proven  of  value  as  yet,  it  comprehends  a  field  of  endeavor 
which  is  along  the  lines  leading  to  successful  results  in  other  con- 
nections, and  for  this  reason  reference  to  the  matter  should  not  be 
omitted  in  a  work  of  this  kind,  if  for  no  other  reason  than  to 
stimulate  investigation  in  this  direction. 


456  PERITONITIS  FOLLOWING   CELIOTOMY 


TREATMENT   OF   PERITONITIS 

The  occurrence  of  peritonitis  is  heralded  by  persistence  of 
pain  after  the  lapse  of  twenty-four  hours  following  the  operation. 
Its  occurrence  must  be  differentiated  from  the  distress  and  disten- 
tion, the  result  of  intestinal  paralysis.  This  subject  has  already 
been  taken  up.  The  condition  of  the  vomit  should  be  scrutinized. 
The  occurrence  of  blood,  more  or  less  altered,  in  the  vomit  arouses 
suspicion  of  peritonitis,  though  it  may  indicate  acute  dilatation 
of  the  stomach.  In  the  latter  instance  it  appears  early ;  the  writer 
has  seen  small  flecks  of  dark  blood  in  the  vomit,  as  the  patient  was 
being  transported  from  the  operating  table.  The  patient  had  been 
subjected  to  celiotomy  for  hysterectomy,  and  infection  before  the 
operation  was  readily  excluded.  Within  twenty-four  hours  an 
acute  dilatation  of  the  stomach  supervened,  though  fortunately 
the  patient  made  an  excellent  ultimate  recovery,  after  appropriate 
measures  of  relief  had  been  employed.  It  may  be  proper  to  re- 
gard a  prognosis  based  on  the  appearance  of  so  small  a  quantity 
of  blood  in  the  vomitus,  as  stated,  a  trifle  pessimistic.  However, 
liberal  gastric  lavage  should  be  employed  in  cases  where  even  a 
minute  quantity  of  blood  appears  in  the  vomit  after  celiotomy, 
and,  indeed,  also  if  there  be  any  doubt  as  to  the  conditions  in  this 
regard.  The  subsequent  behavior  of  the  case  showed  that  infection 
had  not  occurred,  and  the  wound  healed  by  primary  union.  The 
contention  that  "  black  vomit  "  following  celiotomy  is  fatal  is  true 
enough  when  it  is  the  outcome  of  sepsis,  but  if  it  be  due  to  acute 
dilatation  of  the  stomach,  recovery  is  not  to  be  despaired  of. 

A  discussion  of  the  symptomatology  of  peritonitis  does  not  be- 
long here.  However,  it  may  be  proper  to  state  that  the  classical 
symptoms  of  inflammation  as  taught  in  school  are  the  index  in  this 
situation  as  they  are  elsewhere  in  the  body.  As  soon  as  the  indi- 
cations of  peritonitis  are  manifest,  an  attempt  should  be  made  to 
empty  the  gut.  The  persistence  of  vomiting  makes  the  adminis- 
tration of  medicinal  agents  directed  to  this  end  quite  impractic- 
able. Calomel  in  small  doses  is,  perhaps,  most  likely  to  be  of 
service  in  this  connection.  High  enemata,  to  which  a  few  drops 
of  turpentine  have  been  added,  are  the  means  most  likely  to  serve 
the  purpose.     If  an  expulsion  of  flatus  and  some  feces  attend  the 


TREATMENT  OF   PERITONITIS  457 

measure,  the  prognosis  may  be  regarded  as  more  favorable.  The 
administration  of  eserin,  atropin,  and  lavage  of  the  stomach,  as 
already  indicated  in  connection  with  intestinal  paresis,  are  meas- 
ures of  service.  Reopening  of  the  abdomen  for  the  purpose  of 
cleansing  and  draining  the  peritoneum,  is  a  measure  of  doubtful 
utility.  The  shock  of  the  first  operation,  the  exhaustion  attending 
the  peritonitis,  and  the  fact  that  additional  trauma  to  the  peri- 
toneum and  the  necessary  handling  of  the  gut  will  all  enhance  the 
intestinal  paralysis,  would  seem  to  lead  to  the  conclusion  that  the 
measure  is  not  properly  to  be  expected  to  afford  relief.  However, 
this  may  be  said,  if  the  general  condition  of  the  patient  warrants 
the  attempt,  if  cyanosis,  and  venous  stasis  are  not  dominatingly 
established,  the  opening  of  the  abdomen,  at  the  lower  median  por- 
tion, and  the  introduction  of  hot  saline  solution  may  be  justified. 


THE  MURPHY  TREATMENT 

The  Murphy  treatment  has  recently  come  much  into  vogue. 
Gilliam  states  the  cardinal  features  of  the  Murphy  treatment  as 
"  the  Fowler  position,  pelvic  drainage,  and  continuous  drop-by- 
drop  instillation  into  the  rectum  of  a  saline  solution." 

Gilliam  states: 

1.  Drainage  of  the  germ  impregnated  fluids  into  the  pelvis,  where 
absorption  is  least  active,  and  away  from  the  diaphragm,  where 
absorption  is  most  active,  thus  tending  to  diminish  systemic  infec- 
tion.    This  is  accomplished  by  means  of  the  Fowler  position. 

2.  Drainage  of  the  pelvis  to  prevent  stasis  and  accumulation  of 
the  peccant  matters,  which  is  in  furtherance  of  the  same  object.  The 
drainage  is  effected  through  tubes  usually  introduced  through  a  supra- 
pubic incision  to  the  bottom  of  the  pelvis,  though  on  occasions  the 
drainage  may  be  affected  through  the  vault  of  the  vagina. 

3.  Surcharging  the  lymphatics  with  a  saline  solution  to  prevent 
their  taking  up  and  conveying  into  the  general  circulation  the  poison- 
ous products  of  the  pathogenic  germs  themselves.  This  is  effected  by 
rectal  installation. 

It  is  claimed  that  the  saline  infusion  into  the  rectum  is  carried 
by  antiperistalsis  the  full  length  of  the  large  intestine,  and  in  this 
way  the  area  of  absorbing  surface  is  prodigiously  increased.  Xow, 
inasmuch  as  the  large  bowel  possesses  both  an  absorbent  and  excretory 


458  PERITONITIS  FOLLOWING  CELIOTOMY 

function,  I  am  of  the  opinion  that  the  saline  infusion  serves  a  double 
purpose  by  creating  both  an  endosmotic  and  exosmotic  current,  where- 
by the  vascular  channels  are  filled,  on  the  one  hand,  with  innocuous 
saline  solution,  and  the  excretory  products,  including  the  poisonous 
matters,  are,  on  the  other  hand,  swept  into  the  bowel,  to  be  carried 
away  with  the  excretions.  I  have  seen  cases  in  which  a  diarrheal 
discharge  of  distinctly  fecal  character  went  hand  in  hand  with  evi- 
dence of  absorption  of  the  saline  infusion  and  a  gradual  subsidence 
of  septic  manifestations. 

Gilliam  quotes  from  a  communication  sent  him  by  Murphy: 

In  the  last  five  years'  work  in  general  septic  peritonitis,  we  have 
had  forty-seven  cases  of  perforative,  diffuse,  general  peritonitis  oper- 
ated in  the  active  stage,  with  but  two  deaths,  and  neither  of  these  from 
peritonitis.  The  treatment  after  the  operation  in  these  cases  con- 
sisted in  placing  and  retaining  the  patient  in  the  semi-sitting  (Fowler) 
position  (35  to  -15°)  for  three  or  four  days,  administering  large 
quantities  of  saline  solution  by  rectum,  from  six  to  fifteen  quarts  in 
twenty-four  hours;  the  saline  must  be  allowed  to  seep  in,  the  tube 
remaining  constantly  in  position.  ISTo  water  is  given  by  the  mouth, 
as  the  stomach  never  absorbs  it  direct,  and  under  these  conditions  it 
does  not  readily  transmit  it  to  the  intestine  for  absorption.  Mild 
catharsis  should  be  induced  with  small  closes  of  calomel,  beginning 
eight  hours  after  operation.  During  the  transportation  of  cases  of 
general  suppurative  peritonitis  to  the  hospital,  and  during  the  opera- 
tion the  patients  should  be  kept  in  a  semi-sitting  position.  Use  ordi- 
nary vaginal  douche  tips  with  three  openings,  so  that  the  water  can 
flow  into  one  and  the  gas  come  out  of  the  other.  A  single  opening 
tip  will  not  permit  the  gas  to  bubble  back  into  the  can,  and  th£  passing 
of  gas  is  important.  The  can  should  be  elevated  from  four  to  six 
inches  above  the  anal  level.  The  tube  can  be  strapped  permanently 
to  the  body  (the  thigh)  of  the  patient  with  adhesive  plaster,  and  the 
nurse  should  be  carefully  instructed  to  watch  closely  and  not  allow 
more  than  one  and  a  half  pints  of  saline  solution  to  flow  in  from 
forty  minutes  to  one  hour.  The  speed  of  the  flow  must  not  be  con- 
trolled by  forceps  on  the  tube,  but  by  elevation,  or  depression,  of  the 
can.  A  hot  water  bag  should  be  used  to  keep  the  solution  warm. 
(The  can  is  replenished  every  two  hours.)  There  is  no  irritation  of 
the  rectum  and  the  tube  is  not  taken  out  for  days,  the  time  varying 
in  different  patients  and  depending  on  the  virulence  of  the  infection. 
Through  the  drain,  the  tension  of  the  pus  is  kept   low.     With    the 


TREATMENT    OF    PERITONITIS 


459 


saline  irrigation,  these  patients  have  increased  urination  and  increased 
perspiration  when  the  blood  pressure  is  restored. 

Gilliam  employs  for  the  purpose  of  maintaining  the  Fowler 
position  an  adjustable  chair,  which  is  not  unlike  the  so-called 
steamer  chair  used  by  travelers,  which  he  describes  as 

Consisting  of  a  canvas  body  rest  or  hammock,  supported  by  a 
wooden  frame  work,  and  as  its  name  implies,  it  is  capable  of  being 
thrown  into  various  positions  ranging  from  the  upright  to,  or  near 
the  horizontal.  It  is  provided  with  a  leg  rest  which  is  also  capable 
of  being  raised  or  lowered.  Incidentally,  it  is  light  in  construction 
and  can  be  folded  into  a  small  compass  for  easy  transportation. 

Fig.  292  shows  a  patient  postured  as  described  with  the  irri- 
gation can  placed  in  about  the  proper  relationship  to  the  anal  level. 
The  purpose  can  be  achieved  by  raising  the  head  of  the  bed  or  by 


Fig.  292. — Patient  in  the  Fowler  Position  Being  Given  the  Murphy  Instil- 
lation into  Rectum. 


placing  a  bed  rest  beneath  the  patient's  body  at  an  angle  of  35° 
to  45°.  It  will  be  found  expedient  to  place  the  patient's  buttocks 
on  a  goodly  sized  rubber  ring,  to  obliterate  the  acute  angle  which 
the  tube  forms  to  the  position  of  the  body.     The  latter  may  kink 


460  PERITONITIS    FOLLOWING    CELIOTOMY 

the  tube.  A  return0  flow  is,  of  course,  not  provided  for,  for  obvious 
reasons.  Undue  exertion  on  part  of  the  patient  is  to  be  avoided 
for  the  reason  that  drainage  of  the  abdomen  favors  sequential  ven- 
tral hernia. 

The  class  of  cases  in  which  drainage  is  efficient  is  those  in 
which  purulent  peritonitis  already  exists,  and  here  dependent 
drainage  may  accomplish  the  purpose  in  contradistinction  to  those 
cases  in  which  drainage  is  introduced  as  a  prophylactic  measure, 
with  the  view  of  preventing  infection.  This  phase  of  the  subject 
has  already  been  discussed. 

The  tube  drainage  should  be  removed  as  soon  as  the  discharge 
of  purulent  secretions  ceases.  This  is  usually  feasible  on  the  third 
or  fourth  day.  If  improvement  in  the  general  conditions  occurs 
at  the  end  of  twenty-four  hours,  rectal  alimentation  may  be  made 
for  one  injection  and  the  irrigation  interrupted  for  three  hours. 
The  introduction  of  nutritive  elements  by  mouth  will  be  found  to 
be  quite  impossible  during  the  time  that  the  indications  for  con- 
tinuous instillation  exist.  As  soon,  however,  as  the  stomach  toler- 
ates liquids  gastric  alimentation,  under  the  precautions  stated, 
should  be  begun. 

When  peritonitis  follows  celiotomy  the  patient  should  not  be 
permitted  to  leave  the  bed  until  convalescence  has  been  well  estab- 
lished. 


CHAPTEE    XXIII 

OPERATIONS   ON    THE   ABDOMEN    {Continued) 

COMPLICATIONS    IN    CELIOTOMY 

Lung  complications — Parotitis — Hematemesis — Phlebitis  and  thrombosis — Adhe- 
sions following  celiotomy — Abdominal  belts  and  supporters. 

LUNG   COMPLICATIONS 

Pathological  processes  in  the  lungs  follow  celiotomy  more  fre- 
quently than  operations  in  other  situations  of  the  body.  The  ad- 
vent of  asepsis  has  lessened  the  number  of  instances  in  which  these 
complications  occur,  but  there  is  still  a  preponderance  of  lung  dis- 
ease following  celiotomy  as  compared  to  other  operations.  Pneu- 
monia, pleurisy,  bronchitis,  pulmonary  edema,  embolic  infarcts, 
and  abscess  of  the  lung  are  the  processes  most  commonly  encoun- 
tered.    They  may  follow  simple  or  severe  operations. 

The  belief  that  the  afflictions  were  due  to  chilling  of  the  lung 
tissue  by  ether  was  abandoned  when  the  same  complications 
occurred  subsequent  to  operations  made  under  local  anesthesia. 
Moynihan  says: 

It  is  well  known  that  for  a  few  days  after  any  abdominal  opera- 
tion, the  wound  may  feel  stiff  and  sore,  though  it  is  not  actually  pain- 
ful. The  taking  of  a  deep  breath  or  the  act  of  coughing  causes  a 
sudden  "  stitch  "  in  the  wound,  and  the  patient  feels  as  though  a  free 
effort  at  coughing  would  tear  the  wound  edges  apart. 

It  was  suggested  then  that  immobilization  of  the  abdominal 
muscles,  in  the  unconscious  protection  of  the  wound  area  by  the 
patient,  resulted  in  an  accumulation  of  the  bronchial  secretions 
in  the  lung.  A  deep  breath  was  not  taken;  the  breathing  remained 
thoracic  in  type,  and  the  air  passages  were  not  cleared  in  the  act 
of  coughing.     The  lung  then  became  irritated  and  waterlogged  by 

461 


462  COMPLICATIONS    IN    CELIOTOMY 

retained  secretions.  In  favor  of  this  suggestion  is  the  fact  that 
all  forms  of  chest  involvement  are  more  frequent  after  operations 
performed  in  the  upper  abdomen. 

A  factor  which  is,  without  question,  one  of  great  importance  is 
the  chilling  of  the  patient  before,  during  and  after  the  operation. 

The  precautions  necessary  in  this  connection  are  already  taken 
up  (page  162). 

Moynihan  further  states : 

In  some  cases  I  feel  sure  that  the  cause  of  the  lung  implication 
is  to  be  found  in  the  inhalation  of  septic  matter.  This  septic  matter 
may  come  from  the  patient's  own  mouth,  or  it  is  conceivable  that  a 
dirty  inhaler  may  be  responsible  for  it.  Of  the  necessity  for  cleanli- 
ness in  both  these  directions  there  is  no  further  need  to  speak. 

In  some  cases  the  pneumonia  has  been  proven  to  be  due  to  embo- 
lism, the  septic  emboli  being  derived  from  the  operation  area.  In 
operations  upon  the  stomach  or  intestine  in  particular,  thrombosis 
of  veins  may  result  from  unduly  rough  handling  or  from  infection  of 
the  wounds.  Neatness  and  a  certain  dainty  fastidiousness  and  the 
utmost  cleanliness  in  all  operations  are  things  to  be  cultivated. 

There  can  be  little  doubt,  I  think,  that  in  some  cases  the  long 
continuance  of  the  Trendelenburg  position  in  pelvic  operations  is 
productive  of  harm.  The  viscera  are  pressed  against  the  diaphragm, 
whose  freedom  of  action  is  thereby  limited.  There  is  a  congestion  of 
the  lungs  as  a  result  of  the  gravitation  of  blood  to  the  dependent 
parts.  It  is  my  custom  to  perform  the  early  and  late  steps  of  any 
pelvic  operation  with  the  patient  in  the  usual  horizontal.  As  soon 
as  the  Trendelenburg  position  is  necessary,  the  table  is  altered  by  the 
anesthetist  in  a  moment ;  as  soon  as  the  pelvic  part  of  the  operation  is 
completed,  the  table  is  again  made  horizontal.  The  patient,  there- 
fore, remains  the  briefest  possible  time  in  this  constrained  position. 

It  has  become  a  general  custom,  more  especially  among  resident 
officers,  to  give  intravenous  saline  injections  to  all  patients  who  are 
suffering  in  any  serious  degree  from  shock.  The  custom  has  much 
to  recommend  it,  but  I  am  strongly  disposed  to  think  that  it  is  not 
seldom  provocative  of  harm,  for,  in  some  cases,  when  large  quantities 
of  fluid  are  injected,  an  acute  edema  of  the  lung,  with  copious  frothy 
expectoration,  occurs.  On  postmortem  examination  of  such  cases, 
it  can  be  seen  that  there  is  an  acute  edema  of  both  lungs,  the  lungs, 
in  fact,  are  waterlogged.  Saline  infusions  are  remedies  we  cannot 
afford  to  do  without,  but  a  little  more  discretion  than  seems  generally 


LUNG   COMPLICATIONS  463 

customary  should  be  exercised  in  their  administration.  Above  all,  it 
should  be  seen  that  the  fluid  injected  is  of  proper  temperature,  that 
no  air  is  allowed  to  get  into  the  vein,  and  that  the  quantity  injected 
does  not  exceed  three  pints.  As  much  as  five  or  six  pints  has  been 
frequently  given,  but  I  do  not  think  that  as  much  benefit  results  from 
one  large  injection  as  from  two  smaller  ones  given  with  an  interval 
of  twelve  or  twenty-four  hours. 

Professor  Mikulicz  orders  all  his  patients,  after  abdominal  opera- 
tions, to  breathe  deeply  for  a  few  minutes  two  or  three  times  daily, 
in  the  belief  that  the  tendency  to  stagnation  in  the  lung  bases  is  thereby 
relieved  and  broncho-pneumonia  prevented. 

From  the  foregoing  discussion  it  will  be  realized  that,  though  the 
possible  causes  or  influences  giving  rise  to  the  lung  complications  after 
abdominal  operations  are  many,  it  is  not  to  any  one  of  them  that  para- 
mount importance  can*  be  attached.  The  surgeon's  part,  therefore, 
must  be  to  safeguard  his  patient  by  all  means  in  his  power  from  all 
these  harmful  influences,  and  he  will  find  that  by  so  doing  the  risk 
of  the  occurrence  of  these  most  serious  disasters  will  be  greatly  les- 
sened, if  not  entirely  abolished. 

The  treatment  of  the  lung  complications  following  abdominal 
operations  does  not  differ  from  that  which  is  observed  in  the  cases 
ordinarily  seen.  I  have  come  to  place  much  reliance  upon  the  fre- 
quent use  of  the  steam  inhaler  with  or  without  tincture  of  benzoin 
or  other  stimulants.  The  patient  always  expresses  himself  as  much 
relieved,  and  a  copious  expectoration  generally  results  from  each  use 
of  the  inhaler.  A  mixture  containing  digitalis,  vinum  ipecacuanha, 
and  carbonate  of  ammonia  generally  gives  relief. 

Bibergeil  in  3,909  operations  in  Korte's  clinic  found  that 
pneumonia  followed  in  135  of  the  collected  cases,  and  presented 
in  10  instances  the  croupous  or  lobar,  in  98  the  lobular,  and  in 
the  remaining  27  the  hypostatic  form.  Other  complications,  such 
as  pulmonary  embolism  and  abscess,  bronchitis,  pleurisy,  and  em- 
pyema, occurred  in  147  other  cases.  With  regard  to  pneumonia, 
Bibergeil  found  that  this  complication  of  abdominal  surgery  was 
in  no  wise  influenced  by  the  condition  of  the  wound.  Of  the  10 
cases  of  the  septic  lobar  pneumonia  type,  in  8  the  wound  was 
aseptic  and  septic  only  in  two.     He  states  that : 

A  careful  study  of  the  collected  cases  has  led  to  rejection  of  the 
views  that  this  complication  may  be  due  to  infection  by  way  of 
the   lymphatics,   and   to    such    causes    as   exposure    to    cold    of   the 


464  COMPLICATIONS    IN    CELIOTOMY 

surface  of  the  body  or  of  the  peritoneal  cavity  to  abdominal  irrigation, 
and  to  direct  action  of  the  anesthetic.  The  lobular  form,  or  broncho- 
pneumonia, which  is  most  frequently  met  with  after  laparotomy,  is 
regarded  as  being  usually  the  result  of  autoinfection,  due  to  the  aspi- 
ration of  secretions  from  the  mouth  and  pharynx,  whilst  the  patient 
is  under  full  influence  of  an  anesthetic. 

It  is  pointed  out  that  the  interference  with  free  breathing  and 
expectoration,  resulting  from  pain  at  the  seat  of  the  operation 
and  impeded  movements  of  the  incised  abdominal  wall,  must  favor 
very  much  the  development  of  lung  disease  after  laparotomy, 
while  the  resistance  to  the  inflammatory  attack  is  in  many  cases 
much  impaired  in  consequence  of  the  enfeebled  condition  of  the 
patient.  In  concluding,  the  author  recommends,  as  suitable  pro- 
phylactic measures,  thorough  cleansing  of  the"  mouth  and  throat 
and  irrigation  of  the  stomach  before  the  operation;  a  cautious 
administration  of  the  anesthetic,  the  patient's  face  being  turned 
to  one  side  to  permit  a  free  external  flow  of  oral  secretion;  pre- 
vention of  chilling  of  the  surface  of  the  abdomen  during  and 
after  the  operation ;  the  application  of  thick  and  warm  com- 
presses to  the  wound,  and  avoidance  of  tight  bandaging ;  frequent 
change  of  the  patient's  position  in  bed  during  the  after-treatment, 
and  as  speedy  a  release  from  the  recumbent  posture  as  the  state 
of  the  wound  will  allow. 

The  fact,  as  already  stated,  that  lung  complications  follow 
abdominal  section  when  local  anesthesia  is  employed,  suggests 
that  some  of  the  causative  factors  are  due  to  the  factors  which 
Bibergeil  enumerates.  It  must  not  be  forgotten,  however,  that 
septic  emboli  do  locate  in  the  lung  which  may  have  their  origin 
in  the  field  of  operation,  and  no  local  evidence  of  sepsis  in  the 
postoperative  course  of  the  case  be  manifested.  This  is  readily 
understood,  from  a  physiological  viewpoint,  when  the  arrange- 
ment of  the  abdominal  circulation  is  borne  in  mind.  Indeed, 
abscess  of  the  lung  and  empyema  pleuritica  has  frequently  fol- 
lowed abdominal  section  when  the  abdominal  wound  did  not  in- 
dicate septic  infection.  Indeed,  the  same  condition,  i.e.,  abscess 
of  the  brain  and  fatal  meningitis,  has  occurred  under  the  same 
conditions.  Pneumonia  and  pleurisy  complicating  abdominal  sec- 
tion are  both  more  liable  to  be  followed  by  empyema  than  the  or- 
dinary type  of  both  these  diseases. 


PAROTITIS  465 

If  all  the  precautions  mentioned  be  carried  out,  many  factors 
which  may  properly  he  regarded  as  causative  to  lung  complica- 
tions following  celiotomy  will  be  eliminated.  The  attendant  is 
warned,  however,  against  eliminating  the  question  of  chilling  the 
patient  before,  during,  or  after  the  operation.  Complacency  in 
this  regard,  the  outcome  of  the  assumption  that  mechanical  fac- 
tors play  the  most  important  role  in  causation,  is  to  be  depre- 
cated. So  it  is  with  respect  to  change  of  posture  in  the  so-called 
hypostatic  pneumonia.  The  hypostasis  is  most  likely  to  occur 
in  old  and  enfeebled  persons,  and,  while  it  is  true  that  the  re- 
cumbent position  favors  gravitation  of  fluids  to  the  bases  of  the 
lungs,  it  is  also  true  that  the  sitting  posture  is  not  without  danger 
to  the  patient's  heart  under  the  same  conditions.  The  upper  por- 
tion of  the  body  should  be  cautiously  elevated,  under  careful 
espionage  of  rate  and  character  of  pulse,  and  when  marked  al- 
teration in  these  regards  becomes  manifest,  the  recumbent  posi- 
tion is  to  be  again  attained.  Under  no  circumstances  is  the  pa- 
tient to  be  permitted  to  assume  the  upright  position  as  the  result 
of  muscular  effort.  In  some  instances  the  lateral  positions,  varied 
as  to  the  side  turned  upon,  would  seem  to  be  a  rational  indulgence. 
This,  too,  should  be  done  by  the  attendant  and  not  be  the  result 
of  exertion  on  part  of  the  patient. 

PAROTITIS 

Parotitis,  that  is  an  acute  inflammation  of  one  or  both  parotid 
glands,  is  another  occurrence  quite  common  following  abdominal 
section.  In  1887,  Stephen  Paget  collected  the  records  of  101 
cases  and  investigated  their  causes.  He  found  that  in  10  cases 
parotitis  arose  after  disease  or  injury  of  the  urinary  tract;  18 
cases,  parotitis  arose  after  disease  or  injury  of  the  alimentary 
tract;  23  cases,  parotitis  arose  after  disease  or  injury  of  the  ab- 
dominal wall,  peritoneum  or  pelvic  cellular  tissue;  50  cases, 
parotitis  arose  after  disease  or  temporary  derangement  of  the 
generative  organs. 

It  has  been  believed  that  the  preponderance  of  cases  following 
abdominal  section  for  disease  of  the  genital  organs  was  due  to 
the  fact  that  the  opening  of  the  abdominal  cavity  for  pelvic  dis- 
ease was  more   frequently   undertaken   than  for   other   intra-ab- 


466  COMPLICATIONS  IN   CELIOTOMY 

dominal  afflictions.  Also,  that  heretofore  the  custom  was  not  to 
supply  water  to  the  system  following  celiotomy,  and  that  the  dry, 
parched  condition  of  the  mouth  favored  inflammation  of  these 
glands.  It  is  worthy  of  note,  however,  that  surgical  attack  of 
the  female  generative  apparatus  is  followed  quite  frequently  by 
tonsillitis,  even  now,  when  copious  amounts  of  fluid  are  intro- 
duced into  the  system  after  celiotomy.  It  is  also  true  that  ton- 
sillitis frequently  occurs  in  the  newly  married.  It  would  seem 
that,  as  far  as  the  generative  organs  is  concerned,  there  is  a 
peculiar  relationship  between  them  and  the  tonsillar  and  parotid 
tissue,  one  which  is  not  readily  explained. 

The  significance  of  the  subject  lies  in  the  confusion  the  oc- 
currence of  complications  of  this  sort  give  rise  to,  with  regard  to 
standardizing  the  systemic  symptomatology  with  respect  to  wound 
complications.  The  acceleration  of  pulse  rate,  and  increase  of 
temperature  coincident  to  the  complications  mentioned,  arousing 
suspicion  of  other  more  directly  sequential  conditions. 

The  occurrence  of  parotitis,  secondary  to  celiotomy,  has  been 
ascribed  to  several  causes.  It  was  at  first  regarded  as  a  primary 
mumps,  unfil  the  marked  difference  with  respect  to  the  tendency 
to  suppuration  in  the  secondary  form  became  accepted  as  justi- 
fying a  different  conclusion.  The  pyemic  or  embolic  theory  was 
the  one  to  first  receive  general  approval.  Before  the  advent  of 
aseptic  repair  of  wounds,  this  conclusion  seemed  rational  enough, 
but  latterly,  as  the  condition  obtained  in  the  course  of  nonseptic 
wound  repair,  the  theory  was  discarded.  Indeed,  in  those  in- 
stances in  which  infection  of  the  celiotomy  wound  did  occur, 
there  was  frequently  no  evidence  of  thrombosis  which  would 
justify  the  belief  that  the  suppurative  parotitis  was  embolic.  Of 
course  pyemic  parotitis  does  occur  in  the  course  of  sepsis,  but 
then  develops  as  a  part  of  pyemic  processes  in  other  situations. 

Bucknall  states: 

More  recently  the  question  of  embolic  origin  has  been  definitely 
proven  to  be  incorrect,  for  it  has  been  shown  by  microscopical  examina- 
tion that  the  conditions  present  are  different  in  secondary  parotitis 
and  in  parotitis  of  pyemic  origin.  In  the  former  instance,  the  process 
of  inflammation  begins  around  the  ducts  in  the  centers  of  the  lobules 
and,  moreover,  many  lobules  are  simultaneously  affected.  In  the 
latter    (pyemic  type),  the  inflammation  begins  around  the  arteries 


PAROTITIS  467 

which  run  in  the  perilobular  tissue  and  the  inflamed  mass  is  a  single 
one,  involving  the  area  of  gland  tissue  supplied  by  the  particular 
vessel  which  has  been  blocked  by  the  septic  clot. 

Paget  leans  toward  the  sympathetic  theory  already  alluded 
to,  on  the  ground  of  the  peculiar  relationship  between  the  organs 
of  generation  and  the  parotid  gland.  Moynihan  does  not  regard 
this  relationship  as  of  determining  import,  believing  the  process 
in  the  glands  as  always  infective  and  extending  from  the  mouth. 
This  view  is  strongly  supported  by  Ilanau  and  Pilliet. 

Buchnall  presents  this  view  as  follows : 

They  found  on  microscopical  examination  of  sections  of  the  paro- 
tid (1)  that  the  ducts  were  choked  with  debris  containing  micro- 
organisms; and  (2)  that  the  inflammatory  processes  present  invariably 


Fig.  293. — Parotitis.     Infected  Ducts  and  Adjacent  Central  Parts  of  Lobule 
Breaking  Down  to  Form  Abscess  Cavities.     (Rupert  Bucknall.) 

began  around  the  ducts  in  the  center  of  each  lobule,  and  only  spread 
later  to  the  periphery  of  the  lobule  and  the  perilobular  connective 
tissue  in  which  the  blood  vessels  are  situated.  They  concluded,  there- 
fore, that  secondary  parotitis  could  not  be  of  embolic  origin,  or  else 
the  inflammation  would  have  originated  around  the  vessels,  and  that 
32 


468 


COMPLICATIONS    IN    CELIOTOMY 


the  fact  that  inflammation  hegan  simultaneously  in  the  centers  of 
many  lohules  at  once,  pointed  to  an  ascending  infection  of  the  ducts 
as  the  real  source  of  the  affection, — a  conclusion  which  was  further 
borne  out  by  the  actual  presence  of  microorganisms  in  the  ducts  them- 
selves in  such  cases. 

Additional  evidence  of  different  kinds  has  been  subsequently 
brought  forward  in  support  of  this  view. 

Microscopical  sections  serve  to  show  that  in  all  cases  of  secondary 
parotitis,  the  disease  pursues  the  following  course:  (a)  The  ducts 
become  blocked  with  debris  (Fig.  293).  (b)  Inflammation  first  be- 
gins in  the  center  of  each  lobule  around  the  ducts,  and  at  a  point 
farthest  away  from  the  vessels   (Fig.  294).     (c)   Many  lobules  are 


Fig.  294. — Parotitis.  Gland  Tissue  Destroyed  and  Replaced  by  Inflammatory 
Products,  Which  are  Breaking  Down  to  Form  Abcess  Cavities,  Vessels  not 
Thrombosed  or  Specially  Inflamed.      {Rupert  Bucknall.) 


simultaneously  affected;  they  each  become  centrally  necrosed  and 
then  finally,  by  extension,  they  fuse  to  form  a  multilocular  abscess. 
(Fig.  295.) 

Bacteriological  examination,  first  carried  out  by  Girode,  has  served 
to  prove:  (a)  That  several  different  kinds  of  organisms  may  give  rise 
to  secondary  parotitis,  the  commonest  being  the  staphylococcus,  the 
next  frequent  the  pneumococcus,  and  after  that  the  pneumobacillus, 
the  typhoid  bacillus,  and  the  streptococcus,  in  order  of  frequency. 


PAROTITIS  469 

(b)  That  on  taking  cultivations  from  the  gland  itself,  the  pus  con- 
tained in  it,  the  orifice  of  Stensons  duct,  and  the  oral  cavity  respec- 
tively, the  organisms  found  at  each  spot  are  invariably  identical  in 
each  individual  case,  a  fact  which  supports  the  conclusion  that  the 
infection  of  the  gland  spreads  from  the  mouth  via  the  duct,     (c) 


Fig.  295. — Parotitis.'    Showing  Multilocular  Abcesses  in  Ducts  and  General 
Cell,  Infiltration  of  Lobules.     (Rupert  Bucknall.) 

That  the  organism  giving  rise  to  secondary  parotitis  is  by  no  means 
invariably  the  same  as  that  giving  rise  to  the  primary  disease,  during 
the  course  of  which  the  attack  of  parotitis  has  arisen.  Thus,  in  the 
cases  complicating  pneumonia,  the  organism  causing  parotitis  may 
be  the  pneumococcus  or  the  staphylococcus;  in  typhoid  fever,  it  may 
occasionally  be  the  typhoid  bacillus,  but  it  is  much  more  commonly 
the  staphylococcus  or  pneumococcus.  In  embolic  parotitic  due  to 
pyemia,  on  the  other  hand,  the  organism  in  the  parotid  is  invariably 
identical  with  that  giving  rise  to  the  primary  disease  and  the  abscesses 
in  other  parts  of  the  body. 

The  treatment  of  parotitis  does  not  differ  from  that  of  acute 
inflammatory  processes  elsewhere  in  the  body.  The  discussion 
related  above  argues  for  cleanliness  of  the  mouth  prior  to  opera- 
tion (page  362). 


470  COMPLICATIONS    IN    CELIOTOMY 

HEMATEMESIS 

Hematemesis  following  celiotomy  and  its  significance  has 
been  made  the  subject  of  extensive  discussion  under  postopera- 
tive vomiting  and  acute  dilatation  of  the  stomach.  A  repetition 
of  this  would  be  out  of  place.  The  reader  is  referred  to  these 
portions  of  the  work  for  guidance. 

PHLEBITIS   AND    THROMBOSIS 

Phlebitis  and  thrombosis  are  not  infrequent  occurrences,  com- 
plicating abdominal  section,  though,  indeed,  they  are  almost 
usually  sequential  to  operations  on  the  pelvic  organs,  especially 
hysterectomy,  but  have  also  occurred  following  attack  upon  the 
other  abdominal  organs,  including  the  stomach  and  gall-bladder. 

In  the  vast  majority  of  cases  the  phlebitis  occurs  first,  and 
the  formation  of  the  thrombus  is  secondary  to  it.  However,  in 
some  instances,  especially  where  there  is  an  impoverished  condi- 
tion of  the  blood,  the  so-called  "marasmic  thrombosis  "  of  Bill- 
roth occurs,  which  the  latter  attributes  to  increase  of  the  coagu- 
lability of  the  blood,  due  to  an  increase  in  the  proportion  of  cal- 
cium salts. 

The  phlebitis  is  due,  almost  always,  to  infection,  though  it 
does  also  occur  when  the  wound  runs  an  aseptic  course.  It  will 
be  noticed,  however,  that  even  though  the  wound  itself  presents 
at  no  time  evidence  of  inflammation,  the  so-called  reactionary 
temperature,  on  the  second  day  following  the  operation  reaches 
101-J°  F.  The  notion  that  infection  is  the  causative  factor  in 
phlebitis  is  not  absolutely  accepted  by  all  surgeons.  The  fact  that 
it  occurs  most  frequently  after  hysterectomy,  during  which,  of 
course,  an  infective  area  is  invaded,  would  argue  for  the  accu- 
racy of  the  infection  theory.  Phlebitis  has  also  occurred  after 
interval  appendectomy,  but  it  must  be  remembered  that  the  veins 
of  the  mesoapj^endix  are  intimately  connected  with  the  contigu- 
ous large  venous  trunks,  and  that  an  infection  not  of  sufficient 
virulence  to  manifest  itself  at  the  port  of  entrance,  may  still  find 
the  conditions  for  a  favorable  culture  medium  in  a  contiguous 
vein. 

The  saphenous  and  femoral  veins  on  the  left  side  are  the  ones 


PHLEBITIS   AND   THROMBOSIS  471 

most  frequently  involved.  W.  W.  Keen  regards  the  fact  that  the 
left  common  iliac  vein  passes  under  the  right  common  iliac  ar- 
tery, as  a  possible  indirect  cause  of  the  preponderance  of  cases 
of  infection  of  the  veins  on  the  left  side.  Though  this  explanation 
is  not  easy  to  accept,  it  may  be  said  that  there  is  a  certain  causa- 
tive relationship  possible.  Summarizing  the  subject  of  venous 
thrombosis  and  phlebitis,  Moynihan  says: 

Thrombosis  occurs  most  frequently  following  abdominal  operations 
upon  the  lower  part  of  the  abdomen. .  It  is  estimated  to  happen  in  2 
per  cent,  of  all  cases ;  it  is  first  noticed  about  two  weeks  after  the  opera- 
tion; it  is  more  apt  to  afflict  patients  who  are  debilitated  by  long  ill- 
ness, or  whose  condition  is  poor  as  a  result  of  frequent  hemorrhages; 
it  is  found  in  great  preponderance  upon  the  left  side,  where  it  affects 
the  saphenous  and  femoral  veins.  As  a  causative  factor,  sepsis  can 
rarely  be  excluded.     Phlebitis  precedes  the  thrombosis  as  a  rule. 

Cordier  has  collected  records  of  232  cases.  He  gives  the  fol- 
lowing table,  which  shows  the  number  of  cases  following  various 
operations : 

Nephorraphy    9 

Appendectomy — mostly  so-called  aseptic  cases 27 

Cholecystotomy    4 

Oophorectomy  (cystic,  scirrhotic,  etc.) 16 

Hysterectomy,  fibroids,  so-called  aseptic  cases 69 

Vaginal  operations,  character  not  stated 8 

Alexander's  operation   3 

Hernia     4 

Pyosalpinx    7 

Pelvic  operations  not  specified 9 

Abdominal  and  pelvic  operations  not  specified....  56 

Ectopic  pregnancy 4 

Vaginal  hysterectomy  for  cancer    9 

Suspension  of  uterus 7 

Splenectopy    1 

SPECIAL   FEATURES 

In  213  cases,  left  saphenous  or  femoral  veins  affected. 

In  8  cases,  both  left  and  right  veins  affected. 

In  11  cases,  right  veins  alone  affected. 

In  182  cases,  proximal  part  of  vein  first  affected. 


472  COMPLICATIONS  IN  CELIOTOMY 

In  36  cases,  distal  part  of  vein  first  affected. 
In  14  cases,  portion  of  vein  affected  not  mentioned. 
In  166  cases,  sepsis  was  not  present  at  time  of  operation. 
In  56  cases,  no  mention  of  sepsis  or  asepsis  was  made. 
In  10  cases,  there  was  pus  present  at  time  of  operation. 
In  the  great  majority  of  cases  the  first  symptoms  appeared  from 
the  19th  to  the  15th  day. 

In  6  cases,  pleuritic  and  lung  complications. 
In  3  cases,  sudden  death  occurred. 

Cordier  describes  the  clinical  course  as  follows: 

The  usual  onset  of  this  condition  is  marked  by  a  gradually  increas- 
ing pain  along  some  portion  of  the  long  saphenous  vein,  usually  the 
left,  and  most  frequently  just  below  the  saphenous  opening  in  the  fascia 
lata.  This  pain  may  extend  along  the  whole  course  of  the  vein  and, 
as  a  rule,  does  follow  the  vessel  below  the  knee.  An  elevation  of 
temperature  of  from  2°  to  3°  is  noticed,  and  a  proportionately  in- 
creased pulse-rate  is  also  observed.  The  pain  in  the  limb  is  increased 
by  moving  the  limb  or  by  permitting  it  to  remain  in  a  dependent  posi- 
tion, and  is  partially  relieved  by  elevating  the  leg  and  thigh.  On 
examining,  in  many  cases,  there  will  be  noticed  a  redness  along  the 
course  of  the  inflamed  vein  or  veins.  If  seen  early,  no  perceptible 
swelling  of  the  limb  will  be  noticed,  but  within  a  few  days,  if  the  case 
is  a  severe  one,  the  whole  limb  will  be  swollen,  but  more  particularly 
the  calf  of  the  leg.  This  swelling  is  uniform,  and  free  from  discolora- 
tions  or  redness;  in  fact,  the  surface  is  blanched.  Pressure  along  the 
course  of  the  vein  elicits  tenderness,  and  in  the  calf  of  the  leg  the 
tenderness  is  found  all  over  the  posterior  surface.  The  vein  is  hard- 
ened and  rolls  under  the  finger  like  a  tendon,  in  many  cases.  Pres- 
sure, if  continued  for  several  minutes,  may  produce  pitting,  but  not 
so  well  marked  as  in  dropsical  afflictions.  Except  along  the  course 
of  the  superficial  portion  of  the  vein,  which  may  feel  unnaturally 
warm,  there  is  a  death-like  temperature  of  the  surface  to  the  examin- 
ing hand. 

The  patient  should  at  once,  immediately  upon  recognition  of 
the  affliction,  be  warned  of  the  serious  outcome  which  may  attend 
disturbance  of  the  limb.  The  affected  limb  should  be  elevated  on 
several  pillows,  and  warm  applications,  of  boracic  acid,  lead,  and 
opium  wash  or  simple  water  be  made.  The  limb  may  be  incased 
in  a  many-tailed   bandage,    and   thus   the   applications   may  be 


ADHESIONS   FOLLOWING   CELIOTOMY  473 

made  to  the  sides  and  front  of  the  limb  without  disturbing  it. 
Heat  in  some  form  will  be  found  soothing  and  agreeable  to  the 
patient.  If  the  phlebitis  begin  sufficiently  far  down  in  the  course 
of  the  vein,  the  Bier  passive  hyperemia  should  be  tried.  The 
writer  has  found  this  treatment  of  apparent  service  in  cases 
which  permitted  of  the  constriction  being  placed  above  the  seat 
of  inflammation. 

Cellulitis  suppuration  and  abscess  rarely  occur,  and  must  be 
met  in  the  usual  way  when  they  become  manifest.  In  some  in- 
stances it  would  seem  advisable  to  cut  down  on  the  vein  near  the 
saphenous  opening,  deligate  it  and  remove  the  thrombus.  This 
latter  measure  has  been  found  of  signal  service  in  a  number  of 
cases  observed  by  the  writer. 

The  precautions  with  regard  to  keeping  the  limb  quiet  must 
be  assiduously  observed  for  several  weeks,  until  there  is  a  reason- 
able assurance  that  the  process  has  subsided.  Disregard  of  these 
precautions  has  in  no  small  number  of  instances  resulted  in  dis- 
lodgment  of  the  thrombus,  and  embolic  invasion  of  the  lung  and 
heart  with  sudden  death. 

The  intravenous  injection  of  collargol  has  proven  useful  at 
the  hands  of  some  observers.  Its  employment  would  seem  justi- 
fied, if  the  phlebitis  constantly  recur  after  apparent  subsidence 
of  the  primary  .attack.  Its  use  must  be  carefully  executed,  and 
this  under  aseptic  precautions,  together  with  careful  observance 
of  the  rules  laid  down  with  respect  to  intravenous  medication. 

ADHESIONS   FOLLOWING   CELIOTOMY 

Adhesions  following  celiotomy  are  quite  unavoidable.  They, 
of  course,  do  not  always  occur  to  a  considerable  extent  following 
celiotomy  undertaken  for  non-infective  processes.  However, 
they  do  occur  in  a  certain  number  of  cases  of  this  sort,  and  may 
be  regarded  as  inevitable  consequential  occurrences  subsequent 
to  operations  where  peritoneal  inflammation  exists,  or  is  provoked 
as  the  outcome  of  surgical  trauma. 

The  avoidance  of  prolonged  drainage  and  unnecessary  manip- 
ulations within  the  abdomen  during  the  operative  procedure  may 
be  regarded  as  determining  factors  with  respect  to  causation. 

It  may  be  said  that  the  introduction  into  the  abdomen  of  vari- 


474  COMPLICATIONS   IN   CELIOTOMY 

ous  mechanical  substances  with  the  view  of  obviating  the  occur- 
rence of  adhesions  has  not  been  attended  by  favorable  results  in 
this  connection.  The  administration  of  cathartics,  and  leaving  a 
certain  amount  of  saline  solution  in  the  peritoneal  sac,  are  meas- 
ures which  theoretically  should  be  of  some  benefit.  So  is  it  with 
regard  to  the  administration  of  atropin  and  eserin. 

A  discussion  of  the  consequences  of  the  formation  of  adhe- 
sions in  the  peritoneum  and  the  organs  it  covers  does  not  belong 
here.  It  is,  however,  proper  to  state  that  mechanical  obstruction 
of  the  gut  follows  in  a  certain  number  of  cases  which  have  been 
subjected  to  intraperitoneal  surgical  trauma,  and  that  the  ob- 
struction is  most  likely  to  follow  cases  in  which  the  lumen  of  the 
gastrointestinal  tract  has  been  invaded.  The  symptomatology  is 
that  of  intestinal  obstruction  and,  as  a  rule,  does  not  present  it- 
self until  weeks  after  the  operation.  When  the  patient  has  over- 
come the  intestinal  paresis  and  there  has  been  an  interval  of  from 
several  days  to  weeks  of  intestinal  patency,  as  shown  by  the  free 
evacuation  of  feces  and  gas,  and  then  symptoms  of  intestinal  ob- 
struction develop,  the  case  may  quite  properly  be  regarded  as  one 
of  mechanical  obstruction  due  to  adhesions. 

The  measures  of  relief  justified  when  the  obstruction  is  due 
to  intestinal  paresis,  which  involve  stimulation  of  the  gut,  should 
be  avoided  and  the  case  at  once  subjected  to  celiotomy,  destined 
to  remove  or  obviate  the  cause  of  obstruction.  This  postoperative 
complication  is  most  distressing,  calling,  as  it  does,  for  a  second- 
ary major  operation  in  a  case  already  subjected  to  severe  meas- 
ures. It  is,  however,  urged  that  the  attendant  do  not  permit  these 
considerations  to  stand  in  a  causative  relationship  to  delay  in  the 
attempt  to  obviate  the  difficulty. 

It  would  seem  that  massage  of  the  abdomen  as  soon  as  con- 
valescence is  established,  should  have  a  tendency  to  obviate  the 
formation  of  adhesions,  or  at  least  to  aid  in  stretching  those  al- 
ready formed,  thus,  from  a  theoretical  viewpoint,  possibly  avoid- 
ing obstruction  by  kinking.  It  is,  of  course,  quite  impracticable 
to  conclude  as  to  the  value  of  the  massage.  However,  as  persons 
who  have  been  subjected  to  celiotomy  are  apt  to  be  in  poor  gen- 
eral condition  following  the  operation,  employment  of  abdomi- 
nal massage  may  be  justified  on  the  ground  of  the  general  benefit 
as  regards  tone  of  the  gut,  which  follows  its  judicious  use.     A 


ABDOMINAL   BELTS    AND   SUPPORTERS  475 

patient  who  has  been  subjected  to  celiotomy  most  always  relaxes 
the  abdominal  muscles  when  in  the  upright  position,  bringing 
the  thorax  nearer  the  pelvis  in  an  effort  to  relieve  the  tension  on 
the  abdominal  muscles.  This  posture  is  a  favorable  one  as  re- 
gards postoperative  hernia,  and,  if  carried  on  for  a  long  time, 
results  in  a  certain  amount  of  disuse  atrophy  of  the  muscles. 
This  is,  of  course,  objectionable,  and  also  so  because  of  the  round- 
shouldered  pose  of  the  patient.  Some  of  this  is  frequently  the 
outcome  of  timidity,  and  is  seen  more  often  in  females  than  in 
males.  In  these  cases  massage  of  the  abdomen  achieves  a  double 
result,  stimulating  peristalsis  and  toning  up  the  muscles  in  the 
abdominal  wall. 

A  not  inconsiderable  number  of  patients  are  victims  of  con- 
stipation following  celiotomy,  for  obvious  reasons.  Massage  pro- 
vokes a  favorable  outcome  in  this  connection.  Electricity  ap- 
plied to  the  abdomen  at  intervals  is  a  measure  which  may  be 
regarded  as  of  service  in  these  cases. 

ABDOMINAL   BELTS   AND   SUPPORTERS 

It  is  common  practice  to  supply  patients  who  have  been  sub- 
jected to  celiotomy  with  some  form  of  abdominal  supporter  which 
is  to  be  worn  for  periods  varying  from  several  to  six  months  fol- 
lowing the  operation.  Much  has  been  said  with  respect  to  the 
superfluity  of  the  measure.  As  a  matter  of  fact,  the  apparatus 
does  no  harm,  and  probably  is  indicated  when  the  section  is  made 
below  the  umbilicus.  In  young  persons  or  in  women  who  have 
not  borne  children,  the  belt  or  supporter  may  be  dispensed  with, 
provided  primary  union  has  been  obtained  in  the  wound.  Even 
in  the  cases  last  mentioned,  if  the  wound  has  healed  by  granu- 
lation, some  form  of  abdominal  supporter  should  be  worn  for 
several  months  after  convalescence  is  established. 

Later  in  adult  life,  that  is,  after  thirty-five,  the  abdominal 
walls  of  all  individuals  undergo  certain  changes.  The  ribs  flare 
out  at  their  lower  aspects,  and  the  abdomen  attains  a  certain  ro- 
tundity, which  is  not  necessarily  due  to  the  deposit  of  fat,  This 
is  due  in  part  to  relaxation  of  the  muscles,  and  in  part  to  a  physi- 
ological "  dropping  down "  of  all  of  the  abdominal  viscera  in- 
cluding the  liver.     Especially  is  this  true  in  women  who  have 


476  COMPLICATIONS  IN  CELIOTOMY 

borne  several  children.  The  strain  in  these  instances  of  the 
intra-abdominal  pressure  is  brought  to  bear  upon  the  lower  two 
quadrants  of  the  abdomen,  and,  if  a  portion  of  the  abdominal 
wall  is  weakened  as  the  outcome  of  section,  hernia  is  liable  to 
occur.     It  is  the  writer's  belief  that  a  well-fitting  abdominal  sup- 


Fig.   296. — Method  of  Strapping  Abdomen.     Preliminary  Step.     (Kemp.) 

porter  tends  to'  support  the  abdominal  wall  and  lessens  the 
chances  of  hernia,  certainly  during  the  first  few  months  follow- 
ing abdominal  section.  It  is  to  be  remembered,  though,  that  the 
supporter  should  be  removed  at  night  and  massage  and  exercise 
of  the  abdominal  muscles  practiced,  with  the  view  of  obviating 
the  undoubtedly  objectionable  resting  of  the  abdominal  muscles, 
which  may  be  the  outcome  of  the  constant  wearing  of  an  artificial 
support  in  this  situation. 

The  influence  support  has  on  the  lower  two  quadrants  of  the 
abdomen  is  illustrated  by  testing  the  effect  of  strapping  with  ad- 
hesive strips.     Kemp  employs  the  method  shown  in  Figs.   296, 


ABDOMINAL  BELTS  AND  SUPPORTERS 


477 


297,  298.  The  strapping  may  be  done  in  the  way  shown,  begin- 
ning from  below  with  the  patient  in  the  recumbent  position,  im- 
mediately subsequent  to  the  operation,  and  these  may  later  be 
replaced  with  a  belt.  This  method  of  procedure  is  especially 
useful,  following  operations  made  necessary  by  enteroptosis. 
The  material  employed  is  two  and  a  half  inch  moleskin,  zinc 
oxid  plaster,  and  each  strip  is  carried  around  behind  to  the  me- 
dian line,  in  the  oblique  direction  indicated  in  the  illustrations. 
It  will  be  seen  in  the  illustrations  that  the  strips  of  the  second 
layer  (Fig.  297)  cross  those  of  the  first,  and  then  all  the  straps 
are  finally  held  in  place  by  a  third  layer  of  transverse  straps 


Fig.  297. — Method  of  Strapping  Abdomen.     Second  Step.     (Kemp.) 


placed  over  the  points  of  crossing  of  those  underneath  (Fig.  298). 

If  the  celiotomy  wound  be  not  quite  healed,  it  is  dressed  with  a 

few  layers  of  sterile  gauze  and  the  straps  made  to  cross  the  wound. 

The  straps,  of  course,  have  to  be  changed  at  each  subsequent 


478 


COMPLICATIONS    IN    CELIOTOMY 


dressing.      Repeated  strappings  are  not  conducive  to  a  healthy 
condition  of  skin,  and  the  measure  is  to  be  regarded  as  simply  a 


Fig.  298. — Method  of  Strapping  Abdomen.      Final  Step.     (Kemp.) 

temporary  one,  to  be  followed  by  apparatus,  as  is  described  fur- 
ther on. 

It  is  not  sufficient  to  give  the  patient  general  directions,  to  go 
to  an  instrument  maker  or  to  send  to  one  and  purchase  the  sup- 
porter. The  attendant  should  make  the  measurements  himself, 
and  see  the  supporter  in  place  in  order  to 
determine  whether  the  intent  has  been  at- 
tained. 

The  necessary  measurements  are  shown 
in  Fig.  299.  The  illustration  speaks  for  it- 
self, the  dotted  lines  representing  circum- 
ference.     M   should  be  taken   about   eight 

Fig.    299.  —  Lines    of        •      i  -i  ,r  i  •        t  j      a 

,T  inches   above  the  pubis,   L  corresponds   to 

Measurement       for  r  " 

Abdominal  Belt.  the    umbilicus ;    these    two    measurements 


ABDOMINAL  BELTS  AND  SUPPORTERS 


479 


are  horizontal.  L  be- 
gins at  the  pubis  in 
front,  and  crosses  the 
ilium  just  below  the 
anterior  spine  U  and 
extends  ascendingly 
backward  to  a  point 
four  inches  below  the 
posterior  aspect  of  M. 

The     supporter 
should  be  of  elastic  ma- 


FlG. 


300. — Abdominal  Supporter 
Celiotomy. 


Used  after 


terial,  cotton  or  silk,  depending  upon  the 
financial  condition  of  the  patient.  The  char- 
acter of  fabric  is  not  essential  as  long  as  the 
elasticity  is  sufficient  for  the  purpose. 

Tig.  300  shows  a  supporter  made  of  elas- 
tic fabric  which  is  strapped  behind.  The 
two  hooks  are  for  perineal  bands,  which  are 
shown  in  part  attached  to  the  posterior  lat- 
eral aspect  of  the  sup- 
porter. This  appara- 
tus is  simple  and 
effective.  The  belt 
may  be  made  to  lace 
on  the  sides  over  the 
hips  in  cases  where 
the  abdomen  is  boat-shaped  and  the  ilii 
prominent.  The  kind  shown  in  the  cut  will 
be  found  effective  in  the  majority  of  in- 
stances. 

The  patient  must  be  instructed  to  apply 
the  supporter  while  in  the  dorsal  position 
with  the  hips  elevated.  Fig.  303  shows  the 
position  which  the  patient  should  assume 
while  applying  the  apparatus.  This  posi- 
tion gravitates  the  viscera  toward  the  dia- 
phragm, and  the  supporter  maintains  them 

,i  t    ,•  TTi-        oai      i  Fig.  302. —  Abdominal 

there  to  a  relative  extent,     h  lg.  301   shows  ,,„„.. 

■  Supporter  and  Corset 

the  supporter  in  position,  being  worn  over         Combined. 


Fig.  301.  —  Abdominal 
Supporter  in  Posi- 
tion. 


480 


COMPLICATIONS   IN  CELIOTOMY 


Fig.  303. — Adjusting  Lower  Segment  of  Combined  Abdominal  Supporter  and  Corset. 

the  undergarment.  The  perineal  straps  are  not  shown,  hut  should 
always  be  employed  to  prevent  the  supporter  from  slipping  up- 
ward, the  latter  contingency  causing  pressure  from  above,  which, 

of  course,  is  more  undesirable  than  wear- 
ing no  support  at  all. 

Women  patients  frequently  object  to 
the  increase  of  bulk  about  the  lower  ab- 
domen when  the  supporter  is  worn.  In 
these  cases  a  corset  fashioned  in  the  man- 
ner shown  in  Fig.  302  may  be  advanta- 
geously employed.  Of  course,  the  pre- 
vailing fashion  with  regard  to  general 
effect  from  an  artistic  viewpoint  must 
needs  be  disregarded.  The  illustration 
shows  a  combined  supporter  and  corset 
arranged  in  two  pieces  which  are  laced 
separately.  The  lower  segment  is  ap- 
plied while  the  patient  is  in  the  position 
shown  in  Fig.  303,  and  the  upper  portion 
may  be  adjusted  later,  as  shown  in  Fig. 
304.  The  latter  step  may  possibly  be 
sufficiently,  readily  modified  to  produce 
certain  artistic  effects  so  dear  to  the 
feminine  heart.  In  a  general  way,  the 
patient  should  be  admonished  not  to 
draw  the  upper  segment  so  tightly  as  to  force  the  viscera  down- 
ward and  thus,  perchance,  lessen  the  efficiency  of  the  lower  one. 


Fig.  304. — Adjusting  Upper 
Segment  of  Combined 
Abdominal  Supporter 
and  Corset. 


CHAPTEK    XXIV 

OPERATIONS    ON    THE    ABDOMEN    (Continued) 

OPERATIONS    ON    THE    STOMACH 

Gastrostomy — Gastroenterostomy:    Hemorrhage;    Regurgitant    vomiting;    In- 
testinal obstruction;   Ulcer  of  the  jejunum;   Diarrhea — Gastrectomy,   etc. 

GASTROSTOMY 

Gastrostomy  is  usually  done  at  a  time  when  the  patient's  gen- 
eral condition  has  already  suffered  to  a  considerable  extent  as  the 
outcome  of  lack  of  nourishment.  It  is  necessary  to  partake  of 
liquid  food  in  large  quantities  to  maintain  not  alone  life  itself, 
but  to  furnish  the  system  with  resistance.  It  is  a  fortunate  cir- 
cumstance that  the  operation  itself  is  not  attended  with  much 
shock,  and  that  the  exhaustion  following  it  is  not  great.  How- 
ever, ample  provision  should  be  made  to  obviate  shock  which  may 
occur  during  or  immediately  subsequent  to  the  operation. 

When  the  patient  is  about  to  be  operated  upon  an  effort  should 
be  made  to  sterilize  the  stomach  by  the  administration  of  sterile 
food,  as  already  discussed  (page  430).  Gastric  lavage  is  not 
readily  executed,  for  obvious  reasons.  An  attempt,  however, 
should  be  made  to  accomplish  it  by  means  of  a  stomach  tube  of 
narrow  caliber.  Passing  of  the  tube  should  be  carefully  executed, 
as  any  trauma  to  the  seat  of  esophageal  obstruction  will  render 
subsequent  infection  of  the  stomach  wound  more  likely.  Imme- 
diately before  the  operation  and  subsequent  to  the  last  cleansing, 
enema,  a  nutritive  enema  of  peptonized  milk  (cold  process), 
should  be  given.  Severe  manipulations  in  the  region  of  the  anus 
should  be  avoided,  as  it  may  be  necessary  to  nourish  the  patient 
by  the  rectum  for  several  days  following  the  operation,  and  this 
may  be  seriously  interfered  with  if  the  anus  be  irritated.  The 
existence  of  persistent   cough   is   an   objectionable   complication, 

481 


482 


OPERATIONS   ON  THE   STOMACH 


and  should  be  controlled  if  feasible  before  the  operation.  It  is 
easy  to  see  how  coughing  would  interfere  with  union  of  the 
stomach  with  the  anterior  abdominal  wall.  If  cough  be  present 
and  the  operation  be  not  imperatively  indicated,  a  slight  post- 
ponement of  it  is  wise;  if,  however,  the  condition  of  the  patient 
do  not  warrant  the  delay,  it  may  be  necessary  to  administer  suf- 


Fig.  305. — Tube  Leading  into  Stomach  Following  Gastrostomy  Held  in  Place. 

ficient  opiate  immediately  after  the  operation  to  control  the  symp- 
tom, and  this  may  have  to  be  maintained  for  several  days.  It  is, 
of  course,  not  a  desirable  indulgence,  but  is  in  some  cases  the 
lesser  of  the  evils. 

The  operative  technic  most  commonly  employed  at  this  writ- 
ing contemplates  the  formation  of  a  valvular  opening  into  the 
stomach,  this  viscus  itself  furnishing  the  valve.  The  wound  is 
quite  closed,  except  for  the  point  of  exit  of  the  rubber  tube  to  be 
subsequently  used  for  the  purpose  of  introducing  food,  the  usual 
protective  dressing  is  applied,  the  tube,  which  should  be  12  to  16 


GASTROSTOMY 


483 


inches  in  length,  is  led  out  through  the  dressing,  and  after  being 
clamped  at  its  distal  end  is  held  in  place  with  a  safety  pin  (Fig. 
305).  The  feeding  is  done  through  the  tube  without  disturbing 
the  dressing,  which  latter  is,  if  there  be  no  indication  to  the 
contrary,  not  disturbed  until  the  eighth  or  tenth  day.  How 
soon  food  is  to  be  administered  is  a  question  of  some  import- 
ance. In  a  general  way,  it  may  be  said  that  it  is  best  not  to 
administer  any  nourishment  by  the  fistula  for  twenty-four  to 
forty-eight  hours,  though  if  there  be  no  nausea  and  the  patient's 
general  condition  has  been  poor  for  a  considerable  period  of  time, 


Fig.  306. — Introduction  of  Liquid  Nourishment  through  Gastric  Fistula. 

small  quantities  of  sterile  milk,  diluted  50  per  cent.,  may  be  in- 
jected through  the  tube  into  the  stomach.  In  most  cases  rectal 
alimentation  will  meet  the  indications  for  forty-eight  hours  fol- 
lowing the  operation,  and  at  the  end  of  this  time  the  introduction 
of  food  into  the  stomach  may  begin.  At  first  only  small  quan- 
tities of  liquid  food  (2  to  4  oz.)  should  be  introduced,  and  for 
33 


484  OPERATIONS   ON  THE   STOMACH 

the  first  six  days  subsequent  to  the  operation  this  should  be 
sterilized  (page  430).  After  this  time  the  food  need  not  be  sterile. 
Nourishment  is  introduced  by  means  of  a  small  glass  funnel 
which  is  readily  connected  with  the  end  of  the  rubber  tube  (Fig. 
306).  It  will  be  found  convenient  to  use  a  rubber  tube  with  a 
flared  distal  end,  such  as  is  used  for  irrigating  catheters  in  lavage 
of  the  bladder.  After  repair  of  the  wound  takes  place,  it  will  be 
found  irksome  to  the  patient  to  constantly  wear  the  tube.  It  is 
not  wise  to  let  the  serous  surface  with  which  the  valvular  folds 
of  the  stomach  fistula  is  lined  to  lie  in  contact  with  each  other,  as 
they  have  a  tendency  to  contract. 

If  this  happen,  it  will  be  found  that  irrigation  into  the  ex- 
ternal opening  with  a  sterile  saline  solution  will  reestablish  the 
lumen  of  the  canal.  However,  it  is  advisable  to  have  left  in  the 
opening  some  dilating  apparatus  at  all  times.     Fig.  307  shows  a 

plug  made  of  soft  rub- 
ber and  furnished  with 
a  shield.  The  latter 
prevents  the  little  in- 
strument from  slipping- 
into  the  stomach.  The 
apparatus  should  be 
about  three  inches  in 
length    and    be    conical 

Fig.  307. — Soft  Rubber  Obturator  to  be  Worn  .  . 

in  Gastric  Fistula  between  Feedings.  &"    *tS    intragastric    end 

to  obviate  irritation. 
The  writer  has  had  a  patient  wear  this  apparatus  for  eighteen 
months  following  a  Senn  gastrostomy  with  satisfaction  to  the 
patient. 

Gastric  feeding  soon  relieves  the  distressing  thirst  from  which 
these  patients  suffer,  and  they  almost  invariably  gain  weight, 
even  though  the  gastrostomy  have  been  done  for  malignant  dis- 
ease of  the  esophagus.  In  instances  in  which  the  esophageal  ob- 
struction is  due  to  impermeable  cicatricial  contraction,  or  to 
pressure  from  aneurism,  the  gain  in  weight  is  very  marked. 

In  nourishing  the  patient,  an  important  factor  is  that  of  the 
mental  state  the  patient  develops  after  a  time  as  the  outcome  of 
the  necessity  of  feeding  himself  by  a  tube  and,  while  the  saliva 
is  not  essential  to  digestion,  the  act  of  mastication  undoubtedly 


GASTROSTOMY  485 

has  an  influence  upon  nutrition  in  this  much,  that  appetite  is 
stimulated  by  the  act.  Patients  suffering  from  esophageal  ob- 
struction who  have  been  subjected  to  gastrostomy  may  be  said  to 
be  hungry  but  devoid  of  appetite.  It  is  well  to  permit  the  patient 
to  thoroughly  masticate  small  particles  of  ordinary  articles  of  diet 
and  expectorate  the  mass  in  small  quantities  into  the  funnel  from 
which  it  can  be  washed  into  the  stomach  by  the  addition  of  liquids. 
In  the  event  of  the  tube  becoming  obstructed  by  the  particles  of 
food,  the  funnel  may  be  disconnected  and  a  syringe  (Fig.  251) 
filled  with  boullion  inserted  and  the  semi-solid  mass  forced  into 
the  stomach.  The  writer  has  found  that  no  preparation  on  the 
market  for  the  purpose  of  nourishment  will  take  the  place  of  meat 
fiber.  A  means  of  introducing  this  into  the  stomach  has  already 
been  taken  up  in  connection  with  sterile  diet.  However,  for  the 
purpose  of  feeding  a  patient  who  has  a  gastric  fistula,  a  pound 
of  lean  beef  is  mangled  and  shaken  up  with  cold  water.  This 
need  not  be  heated  for  the  purpose,  but  is  sucked  into  the  syringe 
(Fig.  251)  and  forced  into  the  stomach  (Fig.  308).  Cooking 
meat  does  not  increase  its  digestive  characteristics ;  indeed,  it 
lessens  it  and  the  measure  suggested  may  be  advantageously  em- 
ployed once  a  day  or  three  times  a  week.  Indeed,  the  patient  will 
improve  most  rapidly  if  the  physiology  of  digestion  be  borne  in 
mind,  and  the  introduction  of  food  be  based  on  the  well-known 
fact  that  man  is  essentially  on  omnivorous  animal,  and  he  be 
treated  accordingly.  Radical  and  peculiar  views  in  this  connec- 
tion should  be  combated. 

The  fats  are,  of  course,  readily  administered,  as  their  con- 
sistence is  only  a  question  of  temperature.  It  is  true  that  the 
fat  contained  in  milk  is  in  the  form  of  an  exceedingly  fine  emul- 
sion, and  in  a  condition  favorable  to  ready  digestion.  However, 
it  will  contribute  not  a  little  to  the  patient's  conception  of  his 
status  if  fats  be  introduced  in  other  forms.  For  the  purpose,  an 
ounce  or  two  of  butter  slightly  warmed  to  render  it  readily  in- 
troduced, may  be  forced  through  the  tube  into  the  stomach  at  in- 
tervals. A  fatty  soup,  while  not  palatable,  may  be  injected,  and 
the  "  gravy  "  of  roast  meat  may  be  fed  to  the  patient  in  a  similar 
way.  The  carbohydrates  are,  of  course,  soluble  in  water,  and 
present  no  difficulty  with  respect  to  administration.  The  use 
of   the   constituents   of   the    classes    mentioned    will    obviate    the 


486 


OPERATIONS    ON    THE    STOMACH 


necessity  of  too  frequent  feedings,  for  it  is  to  be  remembered 
that  physiologically  digestion  is  an  intermittent  process,  and 
this  fact  should  be  conserved  in  feeding  patients  subjected  to  gas- 
trostomy. 

During  the  intervals  between  feedings  the  plug  shown  above 
(Fig.  307)  is  worn,  and  the  wound  is  cleansed  with  a  mild  solu- 


Fig.  308.- 


-Forcing  Macerated  Beef  into  Stomach  through  Gastric  Fistula  by 
Means  of  Syringe. 


tion  of  carbolic  acid  or  simple  sterile  water  immediately  before 
and  after  feeding.  The  patient  should  be  furnished  with  several 
feeding  tubes,  and  these  should  be  kept  clean.  The  character  of 
the  stools  should  be  subjected  to  examination  at  intervals  with 
the  view  of  determining  which  of  the  articles  of  diet  are  not  com- 
pletely digested.  A  record  of  the  patient's  weight  is  a  useful  in- 
dex as  to  the  nutritive  value  of  the  food  administered. 


GASTROENTEROSTOMY 


487 


GASTROENTEROSTOMY 

Gastroenterostomy  should  be  prepared  for  by  an  attempt  at 
sterilization  of  the  gastric  mucosa.  This  is  more  readily  attained 
than  sterility  of  the  intestinal  lumen  for  the  reasons  above  stated 
(page  424).  In  all  instances  systematic  gastric  lavage  should  be 
practiced  for  some  time  (several  days)  before  the  operation.  The 
operation  is  performed  for  the  purpose  of  draining  the  stomach, 


Fig.  309. — Moynihan   Position  after  Gastric  Operations. 

and  the  conditions  which  provoke  stasis  in  this  organ  also  permit 
of  the  decomposition  of  food,  and  a  certain  amount  and  degree 
of  gastric  inflammation  always  coexists.  This  is  attended  with  a 
coating  of  the  gastric  mucosa  with  a  thick,  tenacious  mucus  se- 
cretion which  is  difficult  to  remove  and  which,  if  left  in  situ,  pre- 
sents exceedingly  favorable  conditions  for  infection.  The  gastric 
lavage  had  best  be  done  by  means  of  solutions  which  will  dissolve 
the  mucous  coating,  thus  rendering  the  efforts  at  sterilization  of 


488  OPERATIONS    ON    THE    STOMACH 

the  interior  of  the  organ  more  readily  executed.  A  teaspoonful 
of  sodium  bicarbonate  to  the  quart  of  sterile  water  or  a  teaspoon- 
ful of  magnesium  sulphate  to  the  quart  of  sterile  water  are  effica- 
cious agents  for  the  purpose.  The  use  of  antiseptic  solutions  of 
sufficient  strength  to  be  efficacious  are  dangerous,  and  should 
not  be  used.  The  administration  of  isoform  is  justifiable  and 
of  service.  The  diet  for  several  days  preceding  the  operation 
should  consist  of  organic  nitrogenized  substances  (sterilized, 
page  430),  and  fats  and  carbohydrates  are  to  be  avoided,  as  the 
latter  are  not  digested  in  the  stomach  and  only  complicate  the 
problem. 

Lavage  of  the  stomach  with  considerable  quantities  of  sterile 
cleansing  solution  immediately  before  the  operation,  when  the  pa- 
tient is  in  the  anteroom  and  under  narcosis,  is  a  measure  which 
gives  additional  security  to  the  operative  procedure  with  respect 
to  the  avoidance  of  infection. 

Immediately  after  patient  regains  consciousness  following 
gastroenterostomy,  he  should  be  postured  in  the  sitting  position 
(Fig.  309 )j  with  the  idea  of  facilitating  drainage  of  the  stomach. 
The  accumulation  of  secretions,  the  outcome  of  a  certain  amount 
of  atony  of  the  stomach,  due  to  handling  together  with  the  over- 
dilatation,  the  result  of  the  affliction  for  which  the  operation  is 
performed,  renders  the  emptying  of  the  stomach  a  difficult  prob- 
lem and  the  supine  position  may  permit  of  collections  in  the  or- 
gan. This  will  be,  in  a  measure,  obviated  by  posturing  the  pa- 
tient as  stated.  The  complications  following  the  operation  may 
be  stated  as  follows : 

HEMORRHAGE 

Hemorrhage  is  of  significance  in  proportion  to  its  amount.  A 
slight  bleeding  always  results  from  the  oozing  of  the  edges  of  the 
wound  and  blood,  more  or  less  changed  in  character  and  appear- 
ance as  the  result  of  the  action  of  the  gastric  digestion,  appears 
in  the  vomitus  in  most  instances.  This  need  not  be  regarded  as 
significant,  however,  if  unattended  with  other  symptoms.  Bleed- 
ing itself  is  rarely  fatal,  though  fatal  cases  from  this  cause  have 
been  reported.  Unless  due  to  some  defect  in  technic  (failure  to 
deligate  the  bleeding  points),  the  appearance  of  blood  in  the  vom- 


GASTROENTEROSTOMY  489 

itus  in  considerable  quantity  suggests  acute  dilatation  of  the 
stomach,  a  condition  which  from  the  nature  of  the  affliction  for 
which  the  case  is  subjected  to  operative  attack,  is  an  exceedingly 
likely  occurrence. 

Hemorrhage  per  sc  will  give  the  characteristic  symptoms  of 
loss  of  blood  in  contradistinction  to  the  clinical  picture  already 
described  under  acute  dilatation  of  the  stomach  (page  277). 
Measures  of  relief  should  be  directed  toward  arrest  of  the  hemor- 
rhage. It  is  doubtful  if  a  secondary  operation,  exposure  of  the 
bleeding  point  or  points  and  ligature  of  them  will  be  recovered 
from.  However,  it  is  wisest  that  it  should  be  undertaken  be- 
fore too  much  time  has  been  expended  in  futile  efforts  to  con- 
trol the  hemorrhage  by  the  introduction  of  hemostatics  into  the 
stomach. 

A  moderate  amount  of  bleeding  with  persistent  vomiting  and 
no  particularly  striking  symptoms  of  loss  of  blood  justifies  lavage 
of  the  stomach,  and  if,  at  the  end  of  several  hours  a  second  lavage 
again  reveals  the  presence  of  accumulation  of  blood  in  the  stom- 
ach, and  at  the  same  time  pallor,  acceleration  of  pulserate  and 
inordinate  thirst  are  manifest,  a  secondary  celiotomy  should  be 
undertaken  without  delay,  as  giving  the  patient  the  best  oppor- 
tunity for  recovery. 

REGURGITANT    VOMITING 

Regurgitant  vomiting,  a  common,  fatal  complication,  has  been 
made  the  subject  of  considerable  study.  The  mechanical  causes 
relate  to  the  method  of  technic  of  the  operation,  i.e.,  the  method 
of  anastomosis.  A  discussion  along  these  lines  does  not  belong 
here.  In  a  general  way  it  may  be  said,  in  this  connection,  that 
the  employment  of  the  more  modern  methods  of  anastomosis  (the 
posterior)  has  made  this  distressing,  and  often  unsurmountable 
postoperative  complication  a  less  frequent  occurrence  than  pre- 
viously obtained.  It  is  also  proper  to  state  here  that  the  influx 
into  the  stomach  of  bile  and  pancreatic  juice  of  themselves  is  no 
longer  regarded  as  a  causative  factor  in  the  problem.  The  latter 
point  has  been  quite  definitely  settled  in  an  experimental  way  on 
the  lower  animals,  and  Moynihan  reports  a  case  of  complete  rup- 
ture of  the  gut  at  the  duodenojejunal  junction,  in  which  he  closed 


490  OPERATIONS   ON    THE    STOMACH 

by  suture  the  torn  end  of  the  duodenum  and  joined  the  jejunum 
to  the  stomach.  All  the  bile  and  pancreatic  juice  flowed  into  the 
stomach  without  any  unfavorable  occurrence  as  the  result.  If  re- 
gurgitant vomiting  persist,  it  is  fair  to  assume  that  a  mechanical 
cause  exists  which  is  only  remediable  by  secondary  operation,  and 
this  should  not  be  postponed  until  the  patient's  condition  becomes 
menacingly  enfeebled.  The  operative  relief  is,  of  course,  not 
properly  discussed  here.  This  does  not  mean,  however,  that  a 
moderate  regurgitation  should  be  looked  upon  with  great  appre- 
hension and,  indeed,  it  is  astonishing  how  readily  a  certain  num- 
ber of  cases  of  this  sort  clear  up  under  copious  gastric  lavage. 
The  lavage  need  only  be  employed  once  in  twenty-four  hours  to 
achieve  relief.  It  may  be  said  that  if  regurgitant  vomit  recur 
within  a  few  hours  after  the  primary  lavage,  the  case  should  be 
subjected  to  careful  scrutiny  with  the  view  of  promptly  employ- 
ing operative  measures  of  relief.  In  the  majority  of  instances  it 
will  be  found  that  the  cause  of  the  disturbance  lies  in  there  having 
been  left  too  long  a  loop  of  jejunum  between  its  beginning  and  the 
site  of  the  anastomosis. 


INTESTINAL    OBSTRUCTION 

Intestinal  obstruction  from  mechanical  causes  follows  in  a  cer- 
tain number  of  cases.  It  is  quite  easy  to  realize  how  the  kinking 
and  snarling  of  the  gut  as  the  outcome  of  normal  structures,  ab- 
normally placed,  may  occur  sequentially  to  an  operation,  involv- 
ing opening  of  the  transverse  mesocolon  or  displacement  of  the 
omentum.  These  cases  differ  in  causation  from  those  presented 
in  intestinal  paresis  or  paralysis  due  to  abolition  of  enervation. 
The  latter  are  at  times  amendable  to  non-operative  treatment ;  the 
former  are  fatal  unless  relief  is  afforded  by  operation. 

The  clinical  picture  of  mechanical  intestinal  obstruction  fol- 
lowing gastrointestinal  anastomosis  does  not  differ  from  that  due 
to  other  causes.  The  differential  diagnosis  between  it  and  intes- 
tinal paralysis  rests  most  upon  the  absence  of  pain  in  the  latter 
instance,  and  the  fact  that  intestinal  paralysis  is  quite  continuous 
with  the  immediate  postoperative  symptomatology,  while  obstruc- 
tion does  not  occur  for  several  days  after  the  operation. 


GASTROENTEROSTOMY  491 

ULCER  OF   THE   JEJUNUM 

Ulcer  of  the  jejunum  after  gastroenterostomy  has  the  same 
etiological  factors  as  obtain  with  duodenal  ulcer.  It  is  consequen- 
tial to  the  operation,  inasmuch  as  the  ulcer  occurs  in  the  jejunum. 
Its  occurrence  is  heralded  by  disturbances  of  digestion,  pain  and 
vomiting,  as  is  ulcer  of  the  duodenum.  Its  possible  occurrence 
should  be  borne  in  mind  during  the  postoperative  treatment,  with 
the  view  of  affording  operative  measures  of  relief. 

DIARRHEA 

Diarrhea  occurs  in  a  small  number  of  cases.  It  is  rarely  fatal, 
though  fatal  occurrences  have  been  reported.  The  cause  of  the 
diarrhea  has  not  been  satisfactorily  explained.  The  theory  that 
the  entrance  of  abnormal  amounts  of  acid  secretion  from  the 
stomach  into  the  intestine,  before  being  subjected  to  the  imme- 
diate neutralizing  effect  of  the  bile  and  pancreatic  juice,  is  not 
accepted  on  the  ground  that  marked  hyperchlorhydria  has  not  been 
observed  in  the  cases  afflicted  with  the  malady.  Attention  to  diet, 
as  subsequently  advised,  the  administration  of  opiates,  isoform, 
naphthol,  and  colic  lavage  relieves  very  soon  the  symptoms  in  the 
majority  of  instances. 

GASTRECTOMY,   ETC. 

The  complications  enumerated  above  are  all  likely  to  occur 
after  gastrectomy,  plastic  operations  for  hour-glass  contraction  of 
the  stomach,  excision  of  ulcers,  and,  indeed,  any  operative  attack 
upon  the  stomach  and  may  be  regarded  as  indicative  of  the  prob- 
lems encountered  after  each  one  of  the  operations  mentioned. 
Gastrostomy  permits  of  introduction  of  food  into  the  stomach, 
which  requires  considerable  exercise  of  its  digestive  functions 
soon  after  the  operation,  because  in  this  class  of  cases  leakage  is 
not  liable  to  occur,  and  the  stomach  itself  has  not  been  the  seat 
of  affliction  impairing  its  functions.  It  would  seem  proper,  there- 
fore, to  discuss  more  extensively  the  question  of  postoperative 
administration  of  food  at  this  time. 

The  introduction  of  food  into  the  stomach  after  operations  in- 
vading its  lumen  should  be  avoided  for  five  days,  if  this  be  fea- 


492  OPERATIONS  ON  THE  STOMACH 

sible,  and  the  patient  fed  by  the  rectnm  (page  291).  The  explana- 
tion of  the  apparent  inconsistency  of  this  advice,  and  the  recom- 
mendation that  copious  gastric  lavage  immediately  subsequent  or 
soon  after  the  operation  is  justifiable,  lies  in  the  fact  that  the 
layage  is  attended  with  muscular  effort  on  part  of  the  stomach 
only  as  the  lavage  is  made,  and  that  the  cleansing  fluid  is  entirely 
withdrawn,  leaving  the  stomach  empty.  On  the  other  hand,  the 
effort  at  digestion  following  the  administration  of  nutritive  sub- 
stances provokes  an  irregular  contraction  of  the  stomach  which  is 
prolonged  over  a  considerable  period  of  time,  and  disturbance  of 
the  line  of  union  may  occur  in  consequence.  It  is  frequently 
noticed  that  distention  of  the  approximated  portions  of  gut  and 
stomach  does  not  result  in  leakage  of  gas  at  the  time  of  the  opera- 
tion, and  the  anastomosis  is  regarded  as  "  tight."  This  is  about 
the  condition  of  affairs  which  obtain  during  cleansing  lavage,  and 
differs  quite  radically  from  those  which  attend  the  movements  of 
the  stomach  during  digestion. 

It  is  true  that  union  of  apposed  peritoneal  surfaces  takes  place 
at  the  end  of  twenty-four  to  thirty-six  hours.  However,  the  union 
is  not  sufficiently  firm  at  the  end  of  this  time  to  warrant  taking 
unnecessary  risks.  This  does  not  mean  that  small  quantities  of 
water  may  not  be  partaken  of  at  intervals  at  the  end  of  twenty- 
four  hours  following  the  operation,  but  it  is  certainly  best  to  omit 
the  introduction  of  fluids  containing  substances  requiring  the  ex- 
ercise of  the  digestive  function  at  an  earlier  time  than  here  men- 
tioned, provided  the  conditions  will  warrant.  It  also  does  not 
mean  that,  if  diarrhea,  or  irritation  of  the  rectum  be  dominant 
factors,  small  amounts  of  liquid  food  might  not  be  taken  by  the 
patient  on  the  fourth  day  after  the  operation.  Yet,  on  general 
principles  the  patient  should  be  nourished  by  rectum  for  five  days 
after  the  operation,  if  this  be  at  all  possible. 

At  the  end  of  this  time  peptonized  milk  in  small  doses,  fre- 
quently repeated,  soups,  boullion,  indeed  liquids  of  any  kind  may 
be  given.  The  chief  reliance  as  far  as  nutrition  is  concerned  may 
be  placed  in  the  milk  and  its  products.  Eggs,  raw  or  slightly 
coagulated,  may  be  given  on  the  seventh  day.  Solid  food  should 
not  be  allowed  for  twelve  days  and,  indeed,  had  best  not  be  taken 
until  at  the  end  of  two  weeks  after  the  operation. 

All  substances  introduced  into  the  stomach  for  a  week  follow- 


GASTRECTOMY  493 

ing  the  operation  should  be  sterile  (page  430).  Of  course  this 
applies  also  to  cleansing  fluids.  While  healing  of  the  apposed  se- 
rous surfaces  undoubtedly  has  taken  place  at  the  end  of  the  five 
days,  the  same  does  not  obtain  with  regard  to  the  mucosa  and,  in- 
deed, when  the  technic  of  the  anastomosis  is  borne  in  mind- — how 
firmly  the  through  and  through  stitching  is  made — it  is  easy  to 
conceive  that  more  or  less  necrosis  of  the  tissues  along  the  line  of 
suturing  is  probable.  This  raw  surface  should  not  be  unneces- 
sarily exposed  to  infection.  The  gastric  secretion  is  only  markedly 
acid  during  digestion,  being  neutral  or  alkaline  in  the  intervals. 
The  avoidance  of  nourishment  by  mouth  for  the  time  mentioned 
may  obviate  the  maceration  of  the  mucosa,  which  would  result 
from  contact  with  the  acid  juice  while  repair  is  going  on.  All  of 
this  can,  of  course,  not  be  avoided,  either  by  abstinence  from  food 
or  by  the  subsequent  sterilization  of  the  ingesta.  However,  the 
dangers  in  this  connection  are  certainly  lessened  by  careful  ob- 
servance of  the  suggestions  offered.  The  care  and  treatment  of 
the  superficial  wound  does  not  differ  from  that  of  celiotomy  made 
for  other  reasons  (page  448).  The  wearing  of  a  supporter  after 
operations  on  the  stomach  is  not  indicated,  unless,  as  is  at  times 
necessary  in  stout  individuals,  the  abdominal  section  is  carried 
below  the  umbilicus,  or  if  extensive  infection  of  the  wound  has 
taken  place,  with'  sloughing  and  loss  of  substance.  In  the  latter 
contingency,  an  abdominal  supporter,  as  described  (page  475), 
made  somewhat  wider  and  devoid  of  the  perineal  straps,  may  be 
worn  as  a  precautionary  measure,  if  the  patient  be  engaged  in  an 
occupation  requiring  the  exercise  of  great  muscular  effort.  In 
women  the  corset  (page  480)  will  be  found  to  answer  the  purpose 
very  well. 


CHAPTEK    XXV 

OPERATIONS   ON    THE  ABDOMEN   {Continued) 

OPERATIONS    ON    THE    INTESTINES 

Enterectomy,      etc.:    The     Diet;    Catharsis;    Fecal     fistula  —  Appendectomy  — 
Appendicostomy — Colostomy  :  Colostomy  pad — Colectomy. 

ENTERECTOMY,   ETC. 

Enterectomy,  enteroanastomosis  of  the  small  intestine,  and,  in- 
deed, operations  contemplating  opening  of  the  lumen  of  the  gut, 
call  for  the  same  local  and  general  preparation  taken  up  under 
celiotomy  and  sterile  diet,  etc.  A  repetition  of  these  measures  is 
superfluous.  It  is  probable  that  comparative  sterility  of  the  small 
gut  requires  for  its  achievement  a  longer  period  of  time  than  ob- 
tains with  respect  to  the  stomach.  This  time  is  not  available  in 
all  instances.  However,  if  the  operative  procedure  is  not  urgently 
indicated,  five  or  six  days  of  preparation  along  the  lines  laid 
down  above  is  desirable. 

The  use  of  mechanical  devices  to  facilitate  anastomosis,  such 
as  the  Murphy  button  and  the  like,  has  been  quite  abandoned. 
However,  unless  the  surgeon  have  some  experience  in  sewing  gut, 
it  is  well  to  have  available  at  the  time  of  the  operation  a  "  Murphy 
button "  or  similar  instrument  to  conserve  speed  in  operating. 
Again,  it  at  times  happens  that  the  general' condition  of  the  pa- 
tient becomes  alarming  during  the  operation,  the  outcome  of  shock, 
and  if  the  operation  need  be  rapidly  completed,  recourse  to  these 
aids  is  justified,  even  though  they  are  less  accurate  in  their  accom- 
plishments than  is  desirable. 

When  the  operation  is  undertaken  for  the  relief  of  acute  ob- 
struction, delay  is,  of  course,  objectionable,  and  the  preparation 
of  the  patient  as  far  as  the  cleansing  of  the  intestinal  lumen  is 
concerned,  must  be  restricted  to  gastric  lavage  and  cleansing  of  the 

494 


ENTERECTOMY,   ETC.  495 

colon  by  enema.  The  former  must  under  no  circumstances  be 
neglected  for  the  reasons  taken  up  under  the  head  of  sterilizing 
the  digestive  tract.  The  after-treatment  in  this  class  of  cases  dif- 
fers only  from  that  of  celiotomy  generally,  inasmuch  as  the  pa- 
tient is  kej3t  in  the  dorsal  position,  unless  for  especial  reasons  the 
semi-sitting  posture  is  indicated  (page  457). 

THE    DIET 

The  diet  following  operations  on  the  small  intestine  should  be 
sterile  for  several  days  after  the  introduction  of  food  by  mouth  is 
begun.  The  time  of  beginning  gastric  feeding  is  not  necessarily 
as  long  after  the  operation  as  is  permitted  to  elapse  following  at- 
tack upon  the  stomach.  In  a  general  way,  it  may  be  said  that  the 
lower  down,  nearer  the  anus  the  operation  is,  the  sooner  may 
gastric  alimentation  begin.  However,  no  food  should  be  given  by 
mouth  for  forty-eight  hours  after  the  operation  in  any  event.  In 
the  meantime,  the  patient  is  nourished  and  stimulated  by  the  lower 
bowel.  Thirst,  this  exceedingly  distressing  symptom  following  all 
operations  involving  the  intestinal  tract,  may  be  more  readily  re- 
lieved in  this  class  of  cases  by  supplementing  the  colic  irrigation 
with  small  doses  of  hot  water  given  by  mouth  within  twenty-four 
hours  after  the  postoperative  vomiting  has  ceased. 

CATHARSIS 

Catharsis  is  a  problem  which  in  these  cases  presents  some  dif- 
ficulties. From  the  viewpoint  of  the  histology  of  wound  repair, 
the  intestine  should  be  kept  quiet  for  several  days  following  the 
operation  to  conserve  repair.  However,  the  administration  of 
agents  destined  to  inhibit  peristalsis  favor  intestinal  paralysis,  and 
this  is  a  serious  complication.  The  attendant  must  take  all  the 
factors  into  consideration. 

Certain  it  is  that  no  cathartic  should  be  administered  after  the 
lumen  of  the  gut  has  been  invaded  for  three  days  after  the  opera- 
tion, and  then  only  if  a  special  indication  for  its  employment  pre- 
sents. It  is  difficult  to  see  just  what  this  indication  may  be,  how- 
ever, if  eserin  and  belladonna  stimulate  peristalsis,  they  may  be 
regarded  as  cathartics  and,  indeed,  act  as  such ;  if  symptoms  of  in- 


496  OPERATIONS   ON  THE  INTESTINES 

testinal  paralysis  develop  they  do  not,  as  a  rule,  constitute  a  men- 
acing factor  for  twenty-four  hours  or  more  subsequent  to  the 
operation,  and  their  administration  should  be  withheld  for  at  least 
this  period  of  time.  Indeed,  the  writer  does  not  administer  cathar- 
tics to  cases  of  intestinal  surgery  for  ten  days  following  the  opera- 
tion, employing  a  sterile  diet  for  five  days  and  daily  cleansing  of 
the  lower  bowel  by  enema,  until  normal  defecation  takes  place,  or 
until  sufficient  time  has  elapsed  to  make  safe  the  use  of  cathartics. 
The  postoperative  complications  following  enteroanastomosis  are 
in  all  respects  similar  to  those  discussed  under  gastroenterostomy 
(page  488),  and  are  met  in  the  same  way. 

FECAL   FISTULA 

Fecal  fistula  may  be  mentioned  in  this  connection  as  occurring 
in  a  certain  number  of  cases.  This,  of  course,  means  infection  of 
the  superficial  wound  and  requires  drainage  (page  185).  When  a 
fecal  fistula  occurs,  the  wound  must  be  cleansed  daily  and  the  skin 
surrounding  it  covered  with  an  ointment  containing  some  anti- 
septic, like  iodoform  or  aristol,  to  obviate  irritation  of  the  skin  in 
the -neighborhood  of  the  wound,  the  result  of  the  discharge.  Fecal 
fistula  frequently  heals  spontaneously,  and  this  need  not  be  de- 
spaired of  even  at  the  end  of  several  weeks  following  the  operation. 
The  care  of  the  superficial  wound,  removal  of  stitches,  the  after 
care  with  regard  to  hernia,  etc.,  are  all  taken  up  under  the  general 
head  of  celiotomy  (page  433,  et  seq.). 

APPENDECTOMY 

Appendectomy  is  frequently  an  emergency  operation.  In  the 
emergency  cases  the  preparatory  measures  described  above  are  of 
necessity  modified  to  meet  the  special  indications.  When  appendec- 
tomy is  done  in  the  intervals  between  attacks,  the  preparation  for 
the  operation  is  in  all  respects  similar  to  that  for  intestinal  sur- 
gery. 

Interval  appendectomy,  being  usually  made  through  an  inter- 
muscular incision,  requires  perhaps  less  prolonged  confinement  in 
the  dorsal  position  than  is  necessary  when  the  approach  it  attended 
with  division  of  the  muscular  fibers.     However,  the  attendant  is 


APPENDECTOMY  497 

warned  not  to  be  hasty  in  this  regard.  Patients  who  have  suffered 
from  a  mild  appendicitis,  and  who  are  willing  to  have  the  appendix 
vermiformis  removed  as  a  precautionary  measure,  are  in  a  meas- 
ure influenced  in  their  willingness  to  be  operated  upon  by  the  con- 
sideration that  only  five  or  six  days  of  confinement  and  ten  days' 
absence  from  the  usual  occupation  will  be  required.  This  is  not  a 
wise  procedure.  Indeed,  even  after  an  intermuscular  appendec- 
tomy the  patient  should  not  be  permitted  to  leave  the  sick  room 
for  ten  days,  and  prolonged  muscular  effort  should  be  refrained 
from  for  two  weeks. 

Of  course,  if  infection  of  the  superficial  wound  occur  as  a 
complication  during  the  postoperative  period,  the  patient  should 
not  be  permitted  to  exert  the  abdominal  muscles  until  repair  of 
the  wound  in  the  muscle  and  aponeurosis  of  the  external  oblique 
has  taken  place.  If  the  appendectomy  or  approach  to  the  site  of 
the  appendix  with  abscess  is  made  and  subsequent  drainage  is 
introduced,  the  confinement  to  bed  should  be  maintained  until 
repair  is  quite  complete.  Fecal  fistula  follows  quite  frequently 
the  ablation  of  the  appendix  when  the  inflammatory  process  in- 
volves the  portion  contiguous  to  the  base  of  the  appendix.  These 
fistulas  usually  heal  spontaneously,  unless  the  infection  is  tuber- 
culous, and  the  care  of  the  wound  is  in  all  resj^ects  similar  to 
that  of  infected  wounds  elsewhere  (page  305),  with  the  excep- 
tion that  drainage  of  the  wound  should  be  provided  for,  and  pack- 
ing introduced  only  in  portions  of  the  wound  to  either  side  of  the 
canal  leading  to  the  opening  in  the  gut.  If  the  packing  interfere 
with  free  egress  of  the  feces,  the  latter  will  at  times  infiltrate  the 
tissues  between  the  muscles,  giving  rise  to  cellulitis  of  consider- 
able magnitude,  and  necessitating  the  making  of  additional  drain- 
age openings.  The  dressing  should  be  changed  daily  or,  in  the 
event  of  free  discharge  of  feces,  twice  daily.  The  introduction 
into  the  fistulous  tract,  if  it  persist  after  the  major  portion  of  the 
wound  is  repaired,  of  tincture  of  iodin  is  a  serviceable  measure. 

The  patient  should  be  kept  quiet  until  healing  is  quite  accom- 
plished, although,  when  only  a  small  fistulous  tract  exists,  he 
may  be  permitted  to  go  about  with  a  firm  abdominal  supporter 
(page  475)  placed  over  the  protective  dressing.  Cases  which 
have  been  subjected  to  intermuscular  appendectomy  and  in  which 
primary  union  has  been   attained   need   not  wear   an   abdominal 


498  OPERATIONS   ON  THE  INTESTINES 

supporter.  However,  it  will  be  best  to  furnish  those  cases  in 
which  drainage  has  been  employed  with  a  bandage,  which  should 
be  worn  for  three  months  after  the  operation.  The  postoperative 
complications  following  appendectomy  are  in  all  respects  similar 
to  those  taken  up  under  gastroenterostomy. 

APPENDICOSTOMY 

Appendicostomy  executed  by  the  intermuscular  method  ren- 
ders infection  of  the  peritoneal  sac  during  the  healing  process 
quite  unlikely.  Some  surgeons  after  developing  the  fact  that  the 
appendix  is  patent,  deligate  it  near  its  point  of  emersion  from 
the  abdomen  and  permit  the  extra-abdominal  portion  to  slough 
off. 

This  measure  is  less  apt  to  result  in  infection  than  the  intro- 
duction of  a  rubber  tube  while  the  isolating  adhesions  arc  being 
formed.  If  the  tube  is  used  it  is  clamped,  but  is  not  brought  out 
through  the  dressing,  as  lavage  of  the  colon  is  not  practiced  until 
sufficient  repair  has  taken  place  to  obviate  the  danger  of  leakage 
of  the  cleansing  fluid  into  the  peritoneal  sac.  The  primary  lavage 
should  not  be  undertaken  for  five  days  after  the  operation.  The 
dressing  need  not  be  changed  during  this  period  of  time,  unless 
some  special  indication  for  doing  so  appear. 

There  is  no  leakage  of  feces  from  the  lumen  of  the  appendix 
after  the  operation,  its  entrance  appearing  as  a  small  dimple, 
which  at  times  secretes  a  small  quantity  of  serous  fluid.  For  this 
reason  the  patient  should  wear  a  square  of  gauze,  several  layers 
in  thickness,  fastened  to  the  portion  of  undergarment  contiguous 
to  the  opening.  When  improvement  of  the  condition  for  which 
the  appendicostomy  is  done  becomes  manifest,  the  irrigations  are, 
of  course,  less  frequently  made.  If  an  interval  of  more  than  five 
days  between  injections  is  regarded  as  advisable,  the  patient  must 
be  instructed  to  pass  into  the  canal  a  glass  rod  or  the  handle  of  a 
steel  nasal  applicator  or  similar  device,  at  the  end  of  the  third 
day  after  the  last  lavage,  in  order  to  assure  patency  of  the  com- 
munication with  the  cecum.  The  appendicostomy  opening  has 
been  known  to  heal  in  six  days,  and  as  the  chronic  inflammatory 
process,  for  the  relief  of  which  the  treatment  is  employed,  is  ex- 
ceedingly liable  to  recur  for  a  period  of  years,  it  is  best  to  obviate 


COLOSTOMY  499 

the  possibility  of  closure  of  the  opening  in  the  manner  stated  for 
this  period  of  time. 

The  technic  of  the  colic  lavage  is  exceedingly  simple.  The 
water  receptacle  is  raised  to  about  four  feet  above  the  wound,  and 
the  distal  end  of  the  connecting  tube  furnished  with  a  wide, 
straight  eye-dropper  which  is  readily  passed  into  the  canal.  The 
temperature  of  the  lavaging  fluid  should  be  about  105°  F. 

The  solutions  employed  vary,  of  course,  with  the  character  of 
the  affliction  from  which  relief  is  attempted.  It  is  not  improb- 
able that  mechanical  cleansing  is  the  most  effective  factor  in  the 
treatment,  and  this  may  be  achieved  by  normal  saline  solution, 
the  salt  being  added  to  sterile  water,  with  the  view  of  obviating 
the  extraction  of  inorganics  from  the  colic  mucosa  consequent  to 
the  use  of  water  alone. 

Patients  past  forty  years  of  life  should  wear  a  light  ab- 
dominal supporter  to  obviate  the  chances  of  a  ventral  hernia.  The 
danger  in  this  regard  is  not  great.  However,  it  is  exceedingly 
exasperating  to  have  a  portion  of  the  cecum  push  its  way  out 
through  the  opening  in  the  muscles.  The  gauze  pad  spoken  of 
may  be  affixed  to  the  inner  side  of  the  supporter.  This  is  quite 
essential,  for  the  supporters  are  not  readily  cleansed,  and  when 
stained  with  secretion  are  liable  to  become  offensive. 

COLOSTOMY 

Colostomy,  being  undertaken  for  relief  of  obstruction,  is  pre- 
pared for  in  respect  to  direct  cleansing  of  the  colon  with  difficulty. 
For  obvious  reasons,  however,  an  attempt  at  irrigation  of  the 
colon  for  several  days  with  a  solution  of  acetozone  fifteen  grains 
to  the  quart  should  be  made.  It  is  not  infrequently  feasible  to 
pass  through  the  stricture  from  below  a  rubber  tube  of  small 
caliber  and  effect  gradually  a  comparative  cleansing  of  the  colon. 
For  the  purpose  the  patient  should  be  placed  in  the  Sims  lateral 
position  (Fig.  346),  with  the  hips  elevated  or  in  the  knee-chest 
posture.  Great  gentleness  in  manipulations  should  be  exercised 
in  the  attempt,  as  the  portion  of  colon  above  the  obstruction  is 
likely  to  be  quite  thin  and  perchance  ulcerated  from  pressure. 
Then,  too,  large  quantities  of  fluid  should  not  be  allowed  to  flow 

into  the  gut  for  the  same  reason.     It  is  at  times  wise  to  precede 
34 


500 


OPERATIONS   ON  THE  INTESTINES 


the  colic  lavage  by  gently  injecting  beyond  the  obstruction  four 
or  six  ounces  of  sterile  olive  oil,  which  will  soften  hardened  por- 
tions of  feces,  and  this  may  be  followed  by  the  careful  introduc- 
tion of  a  solution  of  sodium  carbonate  ^  per  cent,  with  the  view 
of  saponifying  the  mixture  of  oil  and  feces,  thus  facilitating  dis- 
charge of  the  contents  of  the  bowel  through  the  stricture.  The 
precautions  with  respect  to  sterile  diet  should-  be  taken.     The  ad- 


Fig.  310. — First  Step  of  Colostomy.     Appearance  of  Wound.     (Tuttle.) 


ministration  of  cathartics  should  aim  at  liquid  stools  for  a  con- 
siderable period  of  time  preceding  the  operation.  A  more  or  less 
empty  colon  at  the  time  of  the  operation  facilitates  much  the  sur- 
gical technic  and  should  be  attained  if  possible. 

Colostomy  is  almost  always  done  in  two  stages,  unless  the  in- 
dications call  for  immediate  relief  of  obstruction.  In  the  latter 
instance  the  wound  is  treated  in  the  same  way  as  a  fecal  fistula 
(page  496).  When  the  intact  colon  is  brought  into  the  wound 
and  fastened  in  place,  the  immediate  treatment  is  that  of  a  clean 
wound.  The  colon  is  usually  held  in  place  by  a  glass  rod  or  a 
supporting  stitch,  and  the  colon  is  sectioned  on  the  fourth  day 
after  the  primary  operation. 

Fig.  310  shows  the  appearance  of  the  wound  and  colon  when 
the  first  stage  of  the  operation  is  completed,  except  for  tying  of 


COLOSTOMY 


501 


the  sutures  in  the  superficial  wound  which  holds  the  distal  por- 
tions of  the  extra-abdominal  portion  of  the  colon  in  place. 

During  this  time  the  bowel  is  kept  quiet  by  the  administra- 
tion of  ;J  grain  of  morphia  given  under  the  skin.  The  dose 
should  be  repeated  in  twelve  hours  and  usually  need  not  be 
again  repeated. 

At  the  end  of  four  days  the  peritoneal  healing  will  have  suf- 
ficiently progressed  to  render  infection  of  that  membrane  very 
improbable.  However,  the  superficial  wound  will  not  be  healed 
by  this  time,  and  great  cleanliness  and  careful  drainage  of  the 
wound  should  be  maintained  to  prevent  burrowing  of  infective 
secretions.  The  surrounding  skin  should  be  covered  with  an 
antiseptic    ointment.      The    retaining    glass    rod    or    supporting 


Fig.  311. — Incision  of  Protruding  Gut  in  Colostomy.     (Tuttle.) 

stitch  need  not  be  removed  for  eight  days  after  the  operation. 
The  segment  of  gut  below  the  colostomy  should  be  irrigated  daily 
with  a  saline  solution. 

At  the  end  of  four  days  after  the  primary  operation  the  gut 
is  sectioned.  For  the  purpose  Tultle  advises  that  the  colon  be 
divided  across  at  the  center  of  the  protruding  portion  and  then 
sectioned  in  a  longitudinal  direction  (Fig.  311).     By  this  means 


502 


OPERATIONS   ON   THE  INTESTINES 


the  upper  triangular  flaps  roll  backward  and  dry  up.  The 
straight  lower  flap  of  the  lower  segment  of  gut  falls  downward 
and  inward,  practically  closing  the  opening.  The  fecal  discharges 
are  thus  carried  outside  of  the  abdominal  cavity,  and  there  is 
scarcely  any  possibility  of  their  gaining  access  to  the  lower  bowel. 

COLOSTOMY  PAD 

After  convalescence  is  established,  the  patient  wears  a  pad  of 
soft  rubber  held  in  place  by  an  elastic  band  running  about  the 
body  (Fig.  312).     The  pad  is  slipped  into  a  steel  ring  which  per- 


Fig.  312. — Colostomy  Pad  Held  in  Place  over  Artificial  Anus. 


mits  of  easy  removal  of  the  pad.     This  permits  of  interchange 
at  frequent  intervals  of  a  second  similar  pad  which  is  kept  on 


COLOSTOMY 


503 


hand.     The  feces  are  received  in  a  receptacle  fashioned  to  fit  the 
body  (Fig.  313).     The  pad  is  removed  twice  daily,  the  feces  re- 


g.  t i  em  ann  &  co 

Fig.  313. — Receptacle  Suitable  for  Receiving  Feces  from 
Colostomy  Opening. 


ceived  in  the  receptacle   (Fig.   314),  and  the  colon  cleansed  "by 
injecting  saline  solution  into  the  upper  opening  (Fig.  315).     The 


Fig.  314. — Emptying  Colon  into  Receptacle. 

lower  portion  of  the  bowel,  that  distant  to  the  fistula,  is  cleansed 
at  frequent  intervals. 


Fig.  315. — Cleansing  Colon  through  Colostomy  Opening. 


Fig.  316. — Colostomy  Pad  with  Abdominal  Belt  and  Perineal  Straps.     The 
Straps  are  Fastened  to  the  Buttons  on  the  Belt. 

504 


COLECTOMY 


505 


The  pad  is  affixed  to  a  band  which  goes  about  the  body,  the 
latter  being  held  down  by  two  perineal  bands  furnished  with 
buttonholes  to  allow  of  modification  as  to  tension.  Fig.  316 
shows  the  apparatus  complete,  Fig.  317  shows  the  pad  removed 


Fig.  317. 


-Colostomy  Pad  and   Ring.     Pad  Shown  from  Side 
Turned  toward   Fistula  when  Worn. 


and  turned  with  the  side  that  goes  over  the  colostomy  opening 
turned  out.  The  cuts  show  the  facility  with  which  the  pad  may 
be  removed. 

COLECTOMY 

Colectomy  when  followed  by  anastomosis  of  the  sectioned 
colon  and  closure  of  the  abdominal  wound  does  not  call  for  espe- 
cial consideration  beyond  those  taken  up  under  abdominal  sur- 
gery and  colotomy.  It  is  well  to  bear  in  mind  that  the  colon 
does  not  heal  with  the  same  rapidity  as  the  small  intestine  after 


506 


OPERATIONS   ON  THE  INTESTINES 


Fig.  318. 


L 


-Paul  Tubes  in  situ  Connected  with  Rubber  Tubes  for  Drainage  of 
Contents  of  Colon.     (Moynihan.) 


section,    and   also   that   colic   lavage   immediately   following   the 

operation  must  be  avoided, 
for  fear  that  the  line  of 
union  may  be  ruptured. 

Colectomy  and  tempo- 
rary colostomy  is  a  pro- 
cedure which  has  been 
largely  employed  within 
recent  years.  The  method 
unites  laterally  the  ends 
of  the  colic  lumen  and 
drains  both  the  proximal 
and  distal  portions  of  the 
gut.  Fig.  318  shows  the 
operation  completed.  The 
Paul  tubes  (Fig.  319) 
afford  excellent  drainage, 


Fig.  319. 

FOR 


— Paul's   Tube.      Showing  Flanges 
Drainage  Tubes.     (Moynihan.) 


COLECTOMY  507 

and  if  they  are,  as  shown  in  the  illustration  (Fig.  318),  con- 
nected with  rubber  tubes  of  large  caliber,  the  wound  is  not  con- 
taminated by  the  discharges  from  the  gut.  The  rubber  tubes  are 
led  into  a  suitable  receptacle  fastened  to  the  side  of  the  bed,  the 
receptacle  being  partially  filled  with  a  solution  of  corrosive  sub- 
limate, 1  in  1,000,  or  other  antiseptic.  There  is  no  odor,  and  the 
protective  dressing  need  not  be  changed  until  the  usual  time, 
governed  by  the  rules  laid -down  under  celiotomy.  When  the  time 
arrives  for  reestablishment  of  the  continuity  of  the  canal  the 
wound  will  be  found  clean,  an  advantage  of  some  importance. 


CHAPTEE    XXVI 
OPERATIONS    ON    THE   ABDOMEN    {Continued) 

OPERATIONS   ON   LIVEE  AND  FEMALE   PELVIC 

ORGANS 

Hydatid  cysts  of  liver — Hepatic  abscess — Kesection  of  liver — Operations  on 
gall-bladder  and  biliary  passages  —  Cholecystotomy  —  Cholecystectomy — 
Hepaticostomy,  choledocotomy,  chole  and  cholecystenterostomy :  Biliary 
fistula — Transperitoneal    operations   on  the   uterus    and   adnexa. 

The  general  preparation  of  patients  about  to  be  subjected  to 
operative  attack  upon  the  liver  should  take  into  account  the  con- 
siderations taken  up  under  jaundice,  and  its  coexisting  lessening 
of  the  coagulability  of  the  blood  (page  21).  Operations  on  the 
liver  are  likely  to  be  attended  with  severe  bleeding,  because  of  the 
intimate  association  of  the  parenchyma  with  the  walls  of  the 
veins,  and  provision  should  be  made  to  meet  the  indications  in  this 
regard.  The  actual  cautery  should  be  available,  and  the  assistants 
should  test  the  same  before  the  operation  as  to  its  serviceability, 
with  the  view  of  obviating  delay  in  this  connection.  Large  quan- 
tites  of  normal  saline  solution,  a  liberal  number  of  gauze  pads, 
and  proper  provision  for  combating  shock  should  be  available. 
The  local  preparation  does  not  differ  from  that  made  for  celi- 
otomy (page  422). 

HYDATID    CYSTS   OF   LIVER 

Hydatid  cysts  are  usually  drained  after  the  contents  have 
been  evacuated.  In  some  instances  tube  drainage  is  employed, 
but  in  the  majority  of  instances  the  cyst  cavity  is  drained  with 
gauze.  In  a  certain  number  of  cases  a  Mikulicz  tampon  (page 
268)  is  introduced  which  is  removed  at  the  end  of  twenty-four 
hours  and  a  gauze  or  tube-drain  is  placed  into  the  inferior  angle 
of  the  wound,  after  which  the  incision  in  the  abdominal  wall  is 
closed  in  the  usual  manner.     The  shortening  of  the  drain  and  its 

508 


HEPATIC   ABSCESS  509 

ultimate  removal  is  governed  by  the  same  rules  laid  down  in  con- 
nection with  drainage,  discussed  under  that  head  (page  186). 

As  a  rule,  unless  infection  has  complicated  the  cyst  before 
the  operation,  there  is  little  discharge  from  the  wound,  and  it  is 
not  improbable  that  subsequent  purulent  discharges  are  the  out- 
come of  infection,  the  result  of  postoperative  manipulations.  For 
this  reason,  though  moderate  infection  is  attended  with  little 
danger  under  the  circumstances,  care  should  be  taken  in  chang- 
ing the  dressing  to  obviate  this  contingency.  It  is  also  to  be  re- 
membered that  infection  is  more  likely  to  predispose  to  the  occur- 
rence of  ventral  hernia,  although  hernia  in  this  situation  is  not 
common,  for  obvious  reasons. 

Especial  measures  with  respect  to  the  postoperative  care  of 
the  wound  relate  to  the  possibility  of  grafting  of  hydatid  cysts, 
as  the  outcome  of  contact  of  the  contents  of  the  sac  with  the  sur- 
faces contiguous  to  the  wound.  It  is  not  always  possible  to  be 
certain  that  no  minor  residuum  of  cyst  contents  remains  behind, 
and  this  may  contain  the  causative  parasite.  For  this  reason, 
cleansing  of  the  wound  during  the  postoperative  treatment  should 
be  made  with  corrosive  sublimate  solution  or  other  antiseptic,  in 
preference  to  the  use  of  saline  solution  or  sterile  water  for  the 
purpose.  The  use  of  hydrogen  peroxid  is  permissible  when  the 
tampon  is  being  removed,  or  for  the  purpose  of  cleansing  the  cyst 
cavity  immediately  after  its  removal,  i.e.,  when  ready  egress  of 
the  fluid  is  provided  for.  After  the  superficial  wound  is  closed  to 
its  greatest  extent  and  simple  drainage  is  introduced,  the  injec- 
tion of  fluids  into  the  cavity  is  unwise  until  it  is  quite  obliterated 
by  granulation  tissue. 

At  times  a  small  cavity  persists  for  a  considerable  period  of 
time.  It  is  of  service,  in  these  instances,  to  apply  to  the  interior 
of  the  cavity  tincture  of  iodin,  introduced  by  means  of  a  cotton 
pledget  wound  on  an  applicator  or  probe.  This  measure  stimu- 
lates healing  and  destroys  what  slight  infection  may  have  oc- 
curred. 

HEPATIC    ABSCESS 

Hepatic  abscess  is  always  drained  after  the  pus  is  evacuated. 
For  the  purpose  tube-drainage  is  usually  employed  until  the  dis- 


510      OPERATIONS   ON   LIVER  AND   FEMALE  PELVIC   ORGANS 

charge  of  pus  is  very  small  in  quantity,  when  a  cigarette  drain 
or  a  strip  of  gauze  will  meet  the  indications. 

Surgical  attack  of  hepatic  abscess  does  not  involve  any  prob- 
lems as  regards  preparation  of  the  patient  and  subsequent  treat- 
ment not  taken  up  under  celiotomy  and  drainage  after  abdominal 
operations.  The  dressings  should  be  changed  daily  for  a  week 
following  the  operation,  and  thereafter  every  forty-eight  hours 
will  suffice  until  repair  takes  place.  As  adhesion  between  the 
liver  substance  and  the  anterior  abdominal  wall  are  contemplated 
in  the  operative  procedure,  the  occurrence  of  ventral  hernia  is 
not  likely. 

The  writer  approaches  abscess  of  the  liver  through  a  liberal 
celiotomy  wound,  packs  off  the  surrounding  peritoneum,  and  after 
evacuation  of  the  contents  tampons  the  residual  cavity  with  the 
Mikulicz  tampon.  The  packing  is  quite  firmly  introduced.  At 
the  end  of  twenty-four  hours  the  tamponade  is  removed  (page 
268).  At  the  time  of  the  operation  through  and  through  sutures 
are  introduced  into  the  abdominal  wound,  and  these  are  tied  when 
the  tampon  is  removed.  At  this  dressing  a  goodly-sized  "  cigarette 
drain"  (Figs.  154  and  155)  is  introduced  at  the  inferior  angle 
of  -the  wound.  When  the  discharge  of  pus  lessens  silk-worm  gut 
drainage  is  introduced  (Figs.  147  and  148),  and  this  removed 
strand  by  strand  until  the  expulsion  of  inflammatory  exudate 
ceases  entirely. 

After  the  first  forty-eight  hours  following  the  operation, 
drainage  is  conserved  by  posturing  the  patient  in  the  sitting  po- 
sition, similar  to  that  employed  after  gastroenterostomy  (Fig. 
309). 

Abscess  of  the  liver  may  be  regarded  as  most  commonly  due 
to  infection  from  the  gastrointestinal  canal.  An  effort  to  obviate 
the  causative  condition  in  the  digestive  tract  should  be  made  as 
soon  as  the  immediate  postoperative  symptoms  subside.  For  the 
purpose  the  administration  of  intestinal  antiseptics  and  the  use 
of  gastric  lavage  will  be  found  useful. 

The  diet  need  not  be  restricted  in  the  manner  usually  em- 
ployed following  celiotomy  for  invasion  of  the  digestive  tract. 
However,  the  precautions  with  respect  to  postoperative  vomiting- 
should  be  observed,  as  the  straining  of  the  abdominal  muscles  co- 
incident to  the  act  of  vomiting  interferes  with  the  prompt  forma- 


RESECTION   OF   THE   LIVER  511 

tion  of  adhesions  between  the  sectioned  liver  and  the  abdominal 
wall.  The  movements  of  the  diaphragm,  also,  should  be  con- 
.  trolled  as  far  as  feasible  with  the  view  of  aiding  in  the  formation 
of  adhesions  in  this  situation.  For  this  purpose  the  judicious 
use  of  opiates  for  the  twenty-four  or  forty-eight  hours  immedi- 
ately subsequent  to  the  operation  will  be  found  a  useful  measure. 

RESECTION   OF   THE   LIVER 

Resection  of  the  liver  presents  no  special  indications  with  re- 
spect to  postoperative  care.  In  most  instances  the  wound  in  the 
liver  is  repaired  at  once  and  the  abdominal  incision  closed  in  its 
entirety.  In  rare  instances  tamponade  of  the  traumatized  area 
of  liver  is  necessary  with  the  view  of  arresting  hemorrhage.  In 
these  cases  removal  of  the  tampon  and  subsequent  care  of  the 
wound  is  carried  out  along  the  lines  already  laid  down.  On  the 
whole,  the  postoperative  treatment  and  operations  on  the  liver  are 
similar  to  that  of  celiotomy,  and  the  postoperative  complications 
and  their  treatment  are  the  same  as  described  under  that  head. 

Peritonitis  and  intestinal  obstruction,  either  due  to  paralysis 
of  the  gut  or  to  mechanical  causes,  are  less  frequent  in  this  class 
of  cases  than  obtains  following  either  manipulation  or  section  of 
the  intestinal  canal:  As  already  stated,  the  liver  moves  with  res- 
piration, and  operations  which  contemplate  adhesion  of  the  sur- 
face of  the  liver  to  the  anterior  abdominal  wall  should  be  fol- 
lowed by  the  administration  of  opiates  in  sufficient  dosage  to 
control  the  pain  consequent  upon  the  strain  brought  to  bear  on  the 
sutures  introduced  with  the  view  of  fixing  the  liver.  In  instances 
in  which  the  liver  wound  is  closed  and  the  abdominal  section  re- 
paired by  suture  without  drainage  this  need  not  be  considered. 
However,  in  the  class  of  cases  alluded  to,  it  had  best  be  met  in 
the  manner  stated. 

The  tampon  introduced  for  the  purpose  of  arresting  oozing  of 
blood  must  be  carefully  loosened  before  removal,  with  the  view  of 
avoiding  trauma  to  the  clots  obliterating  the  divided  ends  of  the 
hepatic  vessels,  especially  the  veins.  For  the  purpose  the  gauze 
strips  introduced  into  the  "  umbrella  "  gauze  is  thoroughly  moist- 
ened, and,  after  their  removal,  hydrogen  peroxid  is  syringed 
under  the  edges  of  the  outer  layer  of  gauze,  which  will  lift  it  from 


512     OPERATIONS   ON  LIVER  AND  FEMALE  PELVIC  ORGANS 

contact  with  the  surface  of  the  wound.  The  writer  has  used  a 
mixture  of  adrenalin  solution,  a  drachm  to  a  pint  of  hot  saline 
solution  in  this  manner,  with  considerable  success.  Hydrogen 
peroxid  is  not  readily  heated,  and  the  added  atom  of  oxygen  is 
likely  to  be  displaced  by  application  of  the  degree  of  heat  neces- 
sary to  act  as  an  hemostatic.     Cold  peroxid  of  hydrogen  has  some 


Fig.  320. — Sand  Bag  in  Position  for  Approach  to  Biliary  Passages.    (Moynihan.') 

hemostatic  qualities,  but  is  not  as  efficient  for  this  purpose  as  the 
mixture  mentioned. 

It  is  probable  that  the  tamponade  should  not  be  left  in  situ 
for  longer  than  forty-eight  hours  after  the  operation.  The  por- 
tion of  peritoneum  covering  the  liver  is  quite  in  contact  with  the 
lower  surface  of  the  diaphragm,  an  anatomical  fact  which  ex- 
plains the  occurrence  of  hiccough  and  respiratory  difficulties  fol- 
lowing operations  in  this  situation. 


OPERATIONS   ON   THE   GALL-BLADDER   AND    BILIARY 

PASSAGES 

Access  to  the  gall-bladder  and  biliary  passages  is  greatly  en- 
hanced by  placing  under  the  patient's  back  a  sandbag  at,  or  a 
little  above,  the  level  of  the  liver  (Fig.  320).  Modern  operating 
tables  are  supplied  with  an  apparatus  which  achieves  the  object 
and  mav  be  raised  or  lowered   as   desired.      Fig.    87  shows  this 


CHOLECYSTOTOMY 


513 


apparatus  affixed  to  the  operating  table.  By  this  means  the  liver 
is  made  to  be  present  in  the  wound,  and  access  to  the  cystic  and 
common  duct  is  made  comparatively  easy.  In  addition  to  this, 
the  head  of  the  table  may  be  elevated  to  the  extent  of  35°,  caus- 
ing the  intestines  to  gravitate  toward  the  pelvis.  When  the  liver 
is  held  by  retractors  air  enters  between  the  liver  and  intestines, 
making  still  more  accessible  the  operative  field.  A  disadvantage 
of  this  position  is  that  the  abdominal  muscles  are  made  tense, 
and  before  the  wound  of  approach  is  repaired,  the  horizontal  po- 
sition should  be  reassumed  in  order  to  relieve  tension  and  make 
possible  proper  approximation  of  the  abdominal  wound. 

CHOLECYSTOTOMY 


Cholecystotomy,  with  fixation  of  the  gall-bladder  to  the  an- 
terior abdominal  wound,  has  been  quite  abandoned  in  favor  of 


tube  drainage  of  the  gall-bladder. 


and  at  times  fixation  of  the 


Fig.  321. — Drainage  Arrangement  Following  Choubcystotomt. 


fundus  to  the  anterior  peritoneum.  As  frequently  the  parietal 
peritoneum  is  quite  merged  with  the  sheath  of  the  rectus  abdomi- 
nalis,  this  latter  step  is  not  always  feasible  nor  is  it,  indeed,  es- 
sential to  a  favorable  outcome.     This  method  of  dealing  with  the 


514     OPERATIONS   ON  LIVER  AND   FEMALE  PELVIC  ORGANS 


gall-bladder  has  quite  removed  the  necessity  for  prolonged  care 
of  the  wound,  following  the  older  method  of  ventral  fixation.  The 
tube  leading  into  the  gall-bladder  is  connected  by  means  of  a 
glass  pipette  with  a  long  rubber  tube,  which  latter  is  led  into  a 
receptacle  partially  filled  with  an  antiseptic  solution  affixed  to 
the  side  of  the  bed  (Fig.  321).  For  the  purpose  a  wide  tube, 
equivalent  to  26°  F.,  should  be  used.  It  will  be  found  convenient 
to  employ  an  angular  rubber  tube  (Fig.  322),  which,  because  of 

its  conformation,  is  less  likely  to 
kink  than  if  a  straight  tube  is 
used.  Drainage  of  the  surface 
contiguous  to  the  gall-bladder  is 
made  with  a  cigarette  drain, 
which  is  brought  out  at  the  lower 
angle  of  the  abdominal  wound. 
If  no  evidence  of  infection  be 
manifest  at  the  end  of  the  third 
day  following  the  operation,  the 
cigarette  drain  may  be  removed. 
The  tube  drain  is  left  in  the  gall- 
bladder until  the  seventh  day  fol- 
lowing the  operation,  when  it  is 
removed.  The  inverted  serous 
surface  of  the  gall-bladder  comes  in  contact,  as  the  rubber 
drain  is  removed,  and  closes  the  opening  in  a  few  days. 
During  this  latter  time  the  valvular  action  of  the  inverted  gall- 
bladder wall  may  not  be  sufficiently  tight  to  obviate  a  certain 
amount  of  leakage  of  bile.  However,  the  quantity  of  bile  dis- 
charged is  usually  very  small  and  soon  ceases  spontaneously.  In 
any  event,  sufficient  adhesions  of  the  surrounding  peritoneum 
will  have  formed  by  this  time  to  prevent  entrance  of  the  secre- 
tion from  the  biliary  passages  iuto  the  peritoneal  sac.  It  is 
obvious  that  the  point  of  exit  of  the  drain  in  the  gall-bladder 
is  not  the  same  as  that  in  the  superficial  wound,  the  latter 
being  lower  down,  thus  conserving  isolation  of  the  gall-bladder  tract 
by  adhesions. 

Practically  the  same  method  of  procedure  with  respect  to 
drainage  is  employed  when  cysticotomy  is  necessary  for  removal 
of  stone  impacted  in  the  cystic  duct.     The  gall-bladder  is  drained, 


Fig.  322. — Axgulae  Soft  Rubber 
Tube,  Useful  for  Drainage  of 
Gall-bladder  Following  Chole- 

cystotomy. 


HEPATICOSTOMY,   CHOLEDOCOTOMY,   CHOLE,    ETC.         515 

as  stated,  and  a  separate  drain  is  inserted  down  to  the  point  of 
invasion  of  the  cystic  duct.  In  these  cases  it  is  best  to  leave  the 
lower  drain  in  situ  five  days,  until  repair  of  the  wound  in  the 
duct  is  assured. 

CHOLECYSTECTOMY 

Cholecystectomy  with  immediate  closure  of  the  abdominal 
wound  is  rarely  done,  except  perhaps  when  the  gall-bladder  is 
removed  for  neoplasm,  a  rare  condition.  Indeed,  it  may  be  laid 
down  as  a  quite  unmodifiable  rule,  that  drainage  of  the  biliary 
passages  following  invasion  of  their  lumen  is  always  indicated. 
Certain  it  is  that  if  infection  of  the  biliary  passages  have  oc- 
curred, there  is  no  reason  to  assume  that  the  infective  process 
will  reverse  the  general  law  wTith  respect  to  the  action  of  infective 
process  which  in  other  situations  extend  in  the  direction  of  least 
resistance.  It  is,  therefore,  difficult  to  assume  that  infection  is 
more  liable  to  invade  the  gall-bladder  than  the  hepatic  ducts,  and 
if  there  is  one  well-established  law  in  surgery,  it  is  that  drainage 
is  indicated  when  infection  exists. 

The  technic  of  drainage  of  the  biliary  passages  following  chole- 
cystectomy is,  of  course,  not  properly  discussed  here.  Tube 
drainage  is  employed,  and  the  postoperative  care  of  the  wound  is 
in  all  respects  similar  to  that  following  cholecystostomy.  The 
cigarette  drain  which  takes  care  of  the  field  outside  the  biliary 
passages  is  left  in  situ  until  the  fifth  day  following  the  operation 
and  is  then  removed. 


HEPATICOSTOMY,  CHOLEDOCOTOMY,  CHOLE   AND 
CHOLECYSTENTEROSTOMY 

These  procedures  all  present  the  same  picture  as  obtains  with 

the  operations  just  discussed.     The  postoperative  treatment  and 

removal  of  drainage  agents  being  governed  in  a  similar  manner. 

In  this  class  of  cases,  however,  the  rule  is  reversed  and  the  drain 

in  the  area  surrounding  the  tube  is  left  in  after  the  tube  itself 

has  been  removed  from  the  biliary  passages.     That  is,  the  tube 

drain  is  removed  on  the  fifth  day,  and  the  gauze  drain  is  left  in 

place  until  the  eighth  or  tenth  day  after  the  operation,  in  order 
35 


516     OPERATIONS   ON  LIVER  AND   FEMALE  PELVIC   ORGANS 

that  should  there  be  any  leakage  of  bile  after  the  tube  is  removed, 
it  will  be  led  to  the  surface  by  the  latter  drain.  By  the  end  of 
the  tenth  day  the  avenue  of  exit  between  the  biliary  passage  and 
external  wound  will  be  sufficiently  established  to  warrant  allow- 
ing it  to  take  care  of  itself  in  this  respect.  Daily  cleansing  of 
the  wound  at  this  time  will  be  necessary,  which  did  not  obtain 
while  the  rubber  tube  led  away  the  biliary  secretions. 

Biliary  fistula  at  times  follows  this  class  of  operations,  but  in 
the  majority  of  instances  spontaneous  healing  takes  place.  While 
there  is  much  difference  of  opinion  with  respect  to  the  question  as 
to  whether  the  secretion  of  bile  into  the  gut  is  essential  to  life,  it 
is  best  to  give  the  digestive  function  the  benefit  of  the  doubt  in 
the  care  of  cases  in  which  the  biliary  secretion  is  diverted  from 
the  gut  as  the  outcome  of  operative  measures. 

During  the  repair  of  the  wound  and  reestablishment  of  the 
natural  avenue  of  flow  of  the  bile,  the  diet  should  contain  as  little 
fat  as  possible  and  the  quantity  of  carbohydrates  be  reduced.  It 
is  true  that  the  digestion  of  carbohydrates  and  the  emulsification 
of  fats  are  performed  by  the  pancreatic  juice,  yet  there  can  be  no 
doubt  that  the  bile  contributes  not  a  little  to  these  functions. 
Again,  when  the  common  or  hepatic  ducts  are  attacked  it  is  not 
improbable  that  the  entire  duct  is  interfered  with  and  the  pan- 
creatic secretion  is  no  doubt  also  impaired.  The  appearance  of 
bile  in  the  feces  is  the  guide  as  to  when  full  diet  may  be  adminis- 
tered. The  cessation  of  discharge  of  bile  from  the  drainage  open- 
ings does  not  mean  that  full  diet  may  be  partaken  of  at  once. 

Constipation  and  tympanitis  are  common  complications  follow- 
ing operations  which  divert  the  biliary  secretions.  These  are,  of 
course,  taken  care  of  in  the  usual  manner.  However,  it  is  not  im- 
probable that  the  bile  is  an  antiferment,  and  if  the  case  present 
any  especial  difficulty  in  this  connection,  recourse  may  have  to 
be  had  to  the  administration  for  a  few  days  of  sterile  diet  and 
isoform  (page  430).  Gastric  lavage  and  cleansing  of  the  colon 
are  useful  measures,  and  will  afford  considerable  relief  in  in- 
stances where  the  symptoms  are  sufficiently  marked  to  warrant 
their  employment.  The  latter,  that  of  colic  lavage,  may  be  em- 
ployed in  any  event.  The  gastric  lavage,  because  of  the  imme- 
diate contiguity  of  the  field  of  operation  to  the  stomach,  must  not 
be    lightly    undertaken,    though    if    used    judiciously    and    after 


BILIARY   FISTULA  517 

twenty-four  or  more  hours  subsequent  to  the  operation  is  a  justi- 
fiable measure. 

BILIARY   FISTULA 

Biliary  fistula,  as  already  stated,  follows  invasion  of  the 
biliary  passages  in  a  certain  number  of  instances.  When  the 
gall-bladder  has  been  drained  by  a  tube  around  which  it  is  in- 
verted, the  leakage  of  bile  ceases  in  a  few  days  after  the  drain  is 
removed.  However,  a  certain  number  of  surgeons  fasten  the  gall- 
bladder at  the  operation  to  the  abdominal  wall,  with  the  view  of 
obviating  the  occurrence  of  leakage  of  biliary  secretions  into  the 
contiguous  peritoneum. 

This  measure  is  followed  by  copious  discharge  of  bile  through 
the  wound,  which  may  persist  for  several  months.  During  this 
time  frequent  changing  of  the  dressings  is  necessary.  The  skin 
soon  becomes  excoriated,  and  unless  great  cleanliness  is  exercised, 
a  distressing  suppurative  cellulitis  of  the  tissues  about  the  fistula 
occurs.  This  may  be  obviated  by  covering  the  skin  with  a  rather 
thick  layer  of  sterile  zinc  ointment,  with  the  view  of  preventing 
contact  of  the  biliary  secretions  with  the  skin. 

The  ointment  is  gently  removed  once  daily  with  soap  and 
water.  For  the  purpose  a  pledget  of  cotton  is  used,  and  the  oint- 
ment patiently  removed  as  the  outcome  of  prolonged  manipula- 
tion, rather  than  as  the  result  of  harsh,  scrubbing  with  tincture  of 
green  soap  and  a  brush.  It  must  be  remembered  that  the  char- 
acter of  secretion,  coming  from  the  gall-bladder  and  ducts,  is  in- 
fective in  character,  and  that  trauma  to  the  skin  at  this  time  fa- 
vors the  occurrence  of  cellulitis  and  abscess.  The  attendant  may 
assure  his  patient  that  although  a  fistula  of  this  sort  at  times  per- 
sists for  months,  it  will  frequently  heal  spontaneously  at  the  end 
of  this  time. 

The  mucosa  lining  of  the  fistulous  tract  is,  as  a  rule,  much 
thickened  as  the  result  of  an  inflammatory  hyperplasia,  and  this 
membrane  persists  in  secreting  for  a  long  time.  It  will  be  found 
expedient  to  apply  to  the  tract  tincture  of  iodin,  carried  into  the 
lumen  of  the  gall-bladder  at  intervals  by  means  of  cotton  wound 
on  a  probe,  with  the  view  of  destroying  infection  and  stimulating 
repair.  Pure  carbolic  acid  may  be  used  in  the  same  way  at  in- 
tervals of  one  week.     The  latter  should  be  neutralized,  as  far  as 


518      OPERATIONS   ON   LIVER   AND   FEMALE   PELVIC   ORGANS 

contact  with  the  skin  is  concerned,  by  a  liberal  lavage  with  alcohol 
(95  per  cent.),  though  the  alcohol  need  not  be  carried  into  the 
deep  wonnd. 

A  few  days  after  the  application  of  carbolic  acid  sloughing  of 
a  superficial  portion  of  the  tract  occurs,  which  may  interfere 
with  discharge  of  secretion.  This  will  be  manifested  by  evidence 
of  inflammation,  pain,  tenderness  and  a  slight  rise  of  tempera- 
ture. Introduction  of  a  slender  dressing  forceps  will  permit  of 
removal  of  the  slough,  and  the  reassumption  of  drainage  is  soon 
followed  by  disappearance  of  the  manifestations  mentioned. 
During  the  time  that  the  bile  is  copiously  discharged  on  the  skin, 
the  patient  is  apt  to  give  some  evidence  of  malnutrition.  This 
occurs,  of  course,  only  when  the  fistula  remains  patent  for  a  long 
time.  However,  the  constitutional  effect  of  withdrawal  of  the 
biliary  secretion  from  the  gut  has  in  some  instances  caused  suf- 
ficient emaciation  as  to  arouse  suspicion  that  the  process  in  the 
gall-bladder  was  tuberculous.  In  these  instances  secondary  opera- 
tion, with  the  view  of  reestablishing  the  normal  discharge  of  bile 
into  the  gut,  should  be  considered,  and,  indeed,  this  question 
should  be  taken  up  before  the  patient's  general  condition  becomes 
sufficiently  impaired  as  to  influence  the  prognosis  as  regards  the 
operation. 

Patients  who  have  been  subjected  to  operation  upon  the  liver 
do  not  frequently  suffer  from  postoperative  hernia.  However, 
women  past  middle  life,  who  have  thin  recti  muscles  and  a  pendu- 
lous abdomen,  had  best  be  furnished  with  an  abdominal  supporter 
(page  475). 

TRANSPERITONEAL   OPERATIONS    ON    THE    UTERUS    AND 

ADNEXA. 

Approach  to  the  female  pelvis  by  the  abdominal  route  calls 
for  the  same  general  and  local  preparation  described  under  celi- 
otomy. 

Salpingectomy  for  gonorrheal  salpingitis  is  likely  to  be  fol- 
lowed by  infection  of  the  superficial  wound,  and  this  infection  at 
times  does  not  become  manifest  until  the  tenth  or  even  the  four- 
teenth day.  It  is  a  singular  fact  that  evidence  of  peritoneal  in- 
fection may  not,  and  in  the  majority  of  cases  does  not,  manifest 


TRANSPERITONEAL  OPERATIONS  ON  UTERUS  AND  ADNEXA   519 

itself  at  any  time  in  the  vast  majority  of  the  cases  including  those 
which  are  attended  with  infection  of  the  superficial  wound.  This 
would  argue  that  the  peritoneum  is  better  suited  to  take  care  of 
a  certain  amount  of  infection  than  the  abdominal  wound.  There 
is  a  prevalent  notion  that  pyosalpinx  is  an  almost  sterile  process 
after  the  expiration  of  a  certain  period  of  time,  and  this  is  in  a 
measure  true.  However,  this  should  not  engender  a  harmful 
complacency  with  respect  to  asepsis  during  the  operative  proce- 
dure. It  is  not  improbable  that  the  fact  that  there  is  no  wide  solu- 
tion of  continuity  of  the  peritoneum  during  the  operation,  as  com- 
pared to  the  sectioning  of  the  abdominal  wall,  has  some  bearing 
on  the  greater  susceptibility  of  the  latter.  The  abdominal  wound 
presents  a  surface  in  which  the  blood-vessels  and  lymphatics  are 
freshly  sectioned,  and  this  presents  a  more  favorable  condition  of 
affairs  as  regards  infection  than  does  the  smooth  peritoneum, 
which  undergoes  repair  in  a  very  short  time  after  being  injured. 

In  view  of  the  frequency  with  which  infection  of  the  super- 
ficial wound  occurs  following  celiotomy  for  salpingitis,  the  pa- 
tient should  be  kept  in  bed  for  at  least  two  weeks  following  the 
operation.  When  infection  becomes  manifest  the  wound  is  treated 
as  already  described  (page  305). 

Ovariotomy,  hysterectomy,  hysteromyomectomy,  etc.,  are  all 
taken  care  of  as  stated  in  connection  with  celiotomy.  Catheteri- 
zation of  the  bladder  for  postoperative  retention  of  urine  is  more 
frequently  necessary  than  after  operations  on  other  organs  in 
the  abdomen.  This  may  be  due  to  the  trauma  which  the  bladder 
is  indirectly  subjected  to  during  the  operation  in  this  situation. 

The  Trendelenburg  posture  is  more  frequently  employed  dur- 
ing operations  in  the  female  pelvis  than  for  any  other  class  of 
cases.  For  the  purpose  a  table  so  constructed  as  to  permit  of 
placing  the  patient  in  this  position  should  be  available.  Fig.  90 
shows  the  table  placed  in  this  position.  The  nurses  should  be 
careful  to  place  the  patient  in  such  a  position  as  to  permit  of  at- 
tainment of  the  Trendelenburg  position  when  the  necessity  for  it 
arises  without  disturbing  the  relationship  she  bears  to  the  table 
while  in  the  dorsal  posture.  This  is  an  important  consideration, 
as,  if  the  precaution  be  omitted,  the  changing  of  the  patient's 
position  may  result  in  fertilization  of  the  operative  field.  When 
the  patient  is  placed  in  the  Trendelenburg  posture,  the  footpiece 


520      OPERATIONS   ON   LIVER  AND   FEMALE   PELVIC   ORGANS 


of  the  table  is  dropped  by  the  non-sterile  nurse,  the  shoulder 
braces  are  placed  in  contact  with  the  shoulders,  and  the  anesthe- 
tist raises  the  lower  end  of  the  table  by  means  of  the  wheel  (Fig. 


Fig.  323. — Patient  in   Trendelenburg  Position,    Draped  for  Celiotomy. 

323)  until  the  desired  elevation  is  attained.     Fig.  323  shows  the 
patient  placed  in  the  Trendelenburg  posture. 

The  postoperative  complications  following  transperitoneal 
operations  upon  the  uterus  and  adnexa  are  similar  to  those  dis- 
cussed under  celiotomy,  and  are  treated  in  the  same  way.  As  a 
rule,  an  abdominal  supporter  (Fig.  300)  or  a  special  corset  (Fig. 
302)  should  be  worn  for  several  months  after  celiotomy  in  this 
situation,  as  these  organs  are  attacked  through  a  portion  of  the 
abdominal  wall,  which  is  of  necessity  exposed  to  considerable 
strain  and  pressure. 


CHAPTEE    XXVII 

GYNECOLOGICAL   OPERATIONS    BY   THE    PERINEAL 

ROUTE 

Position  of  patient — Isolation  of  operative  field — Irrigation — Care  during  con- 
valescence— The  care  of  the  wound — Vaginal  drainage  of  pelvic  abscess — 
Vaginal  hysterectomy. 

POSITION    OF   PATIENT 

The  vulva  is  shaved  and  cleansed  in  the  manner  described 
under  preparation  of  the  skin.     Catharsis  is  employed  the  day 


Fig.  324. — Position  of  Patient  for  Perineal  Operation.     Surrounding  Parts 
Protected  by  Sterile  Drapery. 

before  the  operation,  and  no  enema  is  given  for  six  hours  before 
the  operation  (page  41). 

The  position  of  the  patient  during  the  operation  most  corn- 

521 


522      GYNECOLOGICAL   OPERATIONS    BY   PERINEAL   ROUTE 

monly  employed  is  the  so-called  lithotomy  posture   (Fig.   324). 
Modern  operating  tables  provide  for  drainage  when  this  position 


Fig.  325. 


-Clover's  Crutch  for  "Lithotomy"  Position  during  Perineal  Opera- 
tions.    (Keyes.) 


is  employed. 


Fig.  326.  —  Adjustable 
Leg-holders  for 
"Lithotomy"  Posi- 
tion in  Operations 
on  the  Perineum. 


However,  if  no  such  arrangement  is  available,  a 
Kelly  pad  (Fig.  13)  is  placed  beneath  the 
buttocks  for  the  purpose.  In  private  prac- 
tice the  lithotomy  position,  if  a  portable 
table  (Fig.  134)  is  not  available,  may  be  at- 
tained by  means  of  the  Clover  (Fig.  325) 
crutch  or  similar  device.  Portable  uprights 
which  clamp  on  the  ordinary  deal  table  and 
are  furnished  with  foot  straps  (Fig.  326) 
are  exceedingly  convenient,  and  do  away 
with  the  strain  upon  the  shoulders  which 
results  when  the  crutch  or  similar  device 
is  used. 

It  will  be  seen  by  the  illustration  that 
the  leg-holders  are  inserted  into  canals  in 
the  clamps  and  held  at  any  desired  height 
by  means  of  the  set  screws.  This  is  desirable 


POSITION   OF   PATIENT 


523 


with  the  view  of  adjustabil- 
ity with  respect  to  varying 
lengths  of  legs.  The  fact  that 
the  clamps  may  be  fastened 
to  the  table  at  any  desired 
distance  from  each  other 
makes  the  holders  adaptable 
with  regard  to  wide  or  nar- 
row buttocks.  In  addition 
to  this,  the  uprights  tele- 
scope, which  arrangement  al- 
lows of  their  transportation  in  a  moderately  sized  bag 


Fig.  327. — Portable  Heel  Cup,  Useful  in 
Cleansing  Perineal  Wounds  after 
Operation. 


The  outfit 
is  also  furnished 
with  heel  cups  (Fig. 
327).  The  uprights 
are  discarded  and 
the  clamps,  after  be- 
ing attached  to  the 
edge  of  the  table,  re- 
ceive the  heel  cups. 
This  arrangement  is 
very  satisfactory 
during  minor  opera- 
tions upon  the  per- 
ineum, etc.,  under- 
taken with  local 
anesthesia,  and  also 
will  be  found  ex- 
ceedingly useful  in 
the  local  treatment 
of  cases  subjected  to 
operations  in  this 
situation  when 
changing  dressings 
treating  the 


Fig.  328. — Miller's  Sponge  Holder.  The  hook  shown 
above,  in  outline,  hangs  loose  on  the  handle  until  the 
forceps  are  locked,  as  seen  in  the  right-hand  figure. 
(Kelly.) 


or 

wound  after  opera- 
tion. When  the  up- 
rights  are  used, 
after    the    case    is 


524      GYNECOLOGICAL   OPERATIONS    BY   PERINEAL   ROUTE 

narcotized,  the  knees  fall  apart  and  the  parts  are  readily  accessible, 
as  shown  in  Fig.  324. 

TYhen  the  patient  is  postured  on  the  table  as  indicated,  the 
vulva  is  again  cleansed  and  the  vagina  sterilized.  For  the  latter 
purpose  tincture  of  green  soap  is  introduced  into  the  vagina,  and 
the  vaginal  walls  scrubbed  by  means  of  a  gauze  sponge  introduced 
with  a  sponge  holder  (Fig.  328).  This  instrument  holds  the 
sponge  firmly  in  its  jaws,  and  the  lock  at  the  handles  does  not 
permit  the  jaws  to  open  while  manipulating  the  instrument  in 
deep  cavities.  The  loss  of  a  sponge  is  no  great  calamity  in  this 
situation.  However,  a  similar  accident  while  the  instrument  is 
introduced  into  the  abdominal  cavity  from  below  would  take  on 
a  serious  complexion. 

The  soap  lather  is  now  displaced  with  an  irrigation  of  warm 
sterile  water,  the  vagina  being  "  ballooned  "  by  holding  the  labia 
in  apposition,  to  distend  the  folds  of  the  mucosa  and  remove  en- 
tirely the  lather.  A  douche  of  10  per  cent,  creolin  is  then  given, 
followed  by  a  copious  vaginal  irrigation  with  corrosive  sublimate 
1  in  2,000,  and  finally  a  douche  of  sterile  water  is  employed. 

ISOLATION    OF   OPERATIVE   FIELD 

The  sterile  isolation  of  the  operative  field  is  accomplished  by 
placing  over  either  leg  and  leg-holder  roomy  leg-covers  made  of 
linen,  which  are  brought  together  over  the  pubis,  giving  space 
enough  over  the  perineum  to  leave  exposed  the  operative  field.  A 
towel  is  placed  transversely  across  the  anus  and  buttocks  and 
fastened  to  the  leg-holder*  on  either  side.  The  abdomen  is  cov- 
ered with  a  sterile  towel.  Fig.  324  shows  the  patient  prepared  as 
stated.  This  method  of  preparation  has  the  advantage  over  that 
of  placing  a  large  sheet  over  the  parts  and  cutting  a  hole  in  it 
corresponding  to  the  operative  field,  inasmuch  as  the  former 
method  permits  of  frequent  changing  of  the  lower  towel  during 
the  operation  with  but  little  disturbance  of  the  contiguous  sur- 
faces and  a  minimum  of  interference  with  the  operative  proce- 
dure. 


IRRIGATION  525 


IRRIGATION 


Irrigation,  though  not  generally  employed  in  operations  in 
other  situations,  should  be  provided  for  in  this  connection.  Dur- 
ing the  operation  a  stream  of  normal  saline  solution  may  be  in- 
termittently directed  against  the  operative  field  in  order  to  facili- 
tate the  manipulations,  such  as  removal  of  blood  which  obscures 
the  field.  For  the  purpose  a  ball  and  socket  nozzle  will  be  found 
convenient  (Fig.  329).     This  little  apparatus  can  be  manipulated 


Fig.  329. — Swedish  Hard  Rubber  Ball  and  Nozzle  Irrigator.     By  bending  the 
nozzle  in  the  ball  at  an  angle,  the  flow  is  controlled  or  altogether  arrested.    {Kelly.) 


with  one  hand,  and  the  force  of  the  stream  readily  controlled  or 
the  flow  may  be  arrested  altogether. 

Following  plastic  operations  in  this  situation,  Kelly  thor- 
oughly drys  the  operative  field  with  pledgets  of  dry  sterile  cotton. 

A  strip  of  iodoform  gauze  may  then  be  inserted  into  the  vagina, 
as  far  up  as  the  cervix,  loosely  filling  the  upper  vagina  and  just  ap- 
pearing at  the  outlet ;  this  should  be  taken  out  in  five  or  six  days  and 
the  vagina  douched  daily  afterward.  It  is  my  practice  at  present  to 
use  no  vaginal  dressing  at  all,  but  simply  to  protect  the  vulva  by  a 
sterilized  gauze  pad  held  in  place  by  a  T-bandage. 

The  pad  is  changed  several  times  daily,  and  if  there  is  any  offen- 
sive discharge,  the  vagina  is  douched  out  with  warm  boric  or  carbolic 
acid  solution  once  or  twice  a  day.  I  have  found  a  powder  composed 
of  boric  acid  3  ounces,  alum  1  ounce,  carbolic  acid  y2  ounce,  and  oil 
of  peppermint  l1/)  drachms,  very  satisfactory  in  relieving  the  odor 
and  irritation  which  are  sometimes  distressing  during  convalescence 
from  a  plastic  operation. 

Before  removing  the  patient  from  the  table,  draw  the  urine  with 
a  glass  catheter,  loosen  the  leg-holder,  and  raise  the  buttocks  by  carry- 
ing the  feet  of  the  patient  toward  the  head,  dry  the  genitals,  buttocks, 
and  back  with  a  towel,  and  remove  the  drainage  pad.  The  external 
genitals  should  be  powdered  with  iodoform  and  boric  acid  (1-7),  and 


526      GYNECOLOGICAL    OPERATIONS    BY   PERINEAL   ROUTE 

then  covered  with  a  loose  pad  of  sterile  cotton,  held  in  place  by  a  T- 
bandage.     (Kelly.) 

CARE   DURING   CONVALESCENCE 

The  care  during  convalescence  frequently  determines  the  ulti- 
mate result.  While  the  patient  is  coming  out  of  narcosis  the  legs 
may  be  tied  together  with  a  broad  towel,  to  obviate  strain  upon 
the  sutures.  As  soon  as  consciousness  returns,  the  restraint  should 
be  removed  and  the  cooperation  of  the  patient  depended  upon  to 
avoid  this  occurrence.  Following  operations  upon  the  perineum, 
the  patient  is  confined  to  bed  for  two  weeks,  during  which  time 
the  bed  pan  is  used.  Evacuation  of  the  bladder  and  rectum  in 
the  sitting  posture  brings  strain  to  bear  on  the  sutures  and  should 
be  avoided.  When  the  cervix  uteri  alone  is  involved,  the  patient 
may  leave  the  bed  on  the  seventh  day  after  the  operation,  and 
may  empty  the  bladder  and  rectum  in  the  sitting  position  after 
the  third  day. 

The  vaginal  pack  may  be  removed  when  discharges  appear  at 
the  vulva,  though,  as  a  rule,  the  pack  may  be  left  in  place  for  six 
days  following  the  operation.  In  removing  the  pack  the  labia 
should  be  carefully  separated  and  the  gauze  thoroughly  moist- 
ened with  an  antiseptic  solution,  which  at  the  same  time  removes 
the  secretions  from  the  labia.  The  pack  is  then  seized  with  dress- 
ing forceps,  care  being  taken  not  to  pinch  in  at  the  same  time  the 
contiguous  mucous  membrane.  With  a  twisting  motion  the  pack 
is  slowly  and  gently  loosened,  as  is  described  under  removal  of 
the  ^Mikulicz  tamponade  (page  268),  and  removed.  The  nozzle  of 
the  irrigator,  which  should  be  blunt,  is  introduced  downward  and 
backward,  and  the  vagina  cleansed  with  a  copious  lavage.  After 
the  douche  the  parts  are  dried  with  sterile  gauze  and  dusted  with 
aristol  or  the  powder  mentioned  above. 

Catheterization  in  these  cases  deserves  special  consideration. 
The  urine,  when  passed  spontaneously,  very  soon  soils  the  oper- 
ative field,  and,  while  the  parts  may  be  cleansed  before  and  after 
the  act  of  urination,  it  is  probable  that  catheterization  at  inter- 
vals of  eight  hours  for  three  days  after  the  operation  is  a  better 
plan  of  procedure.  The  introduction  of  the  catheter  is  performed 
in  the  following  manner : 

The  labia  are  gently  separated  and  the  mucosa  contiguous  to 


THE   CARE   OF   THE   WOUND  527 

the  urethral  meatus  is  cleansed  with  pledgets  of  sterile  cotton 
soaked  in  1  in  200  carbolic  acid  solution.  The  catheter,  which 
should  be  of  glass  and  boiled  before  use,  is  then  passed,  and  after 
the  bladder  is  evacuated  the  parts  are  again  treated  in  the  manner 
employed  before  introduction  of  the  catheter.  If  a  skillful  nurse 
or  a  physician  is  available,  the  latter  measure  is  more  certain  in 
result  as  regards  cleanliness  of  the  perineal  wound.  However,  if 
these  conditions  are  not  obtainable,  the  method  of  preliminary 
and  subsequent  cleansing  is  attended  with  less  danger  of  infec- 
tion, provided  no  cystitis  has  existed  before  the  operation.  In  the 
latter  event,  the  catheterization,  together  with  bladder  lavage, 
should  be  employed.  When  the  catheter  is  withdrawn  the  finger 
should  be  placed  over  its  distal  opening  to  prevent  dribbling  of 
the  urine  contained  in  its  lumen  over  the  wound.  During  these 
manipulations  rubber  gloves  should  be  worn,  which  will  make 
contamination  less  liable  to  happen.  Subsequent  to  either  of  the 
manipulations  the  parts  are  dusted  with  one  of  the  antiseptic 
powders  mentioned. 

Catharsis  is  provoked  on  the  second  day  after  the  operation. 
A  cathartic  is  given  the  evening  of  the  second  day,  and  this  sup- 
plemented by  an  enema  the  following  morning.  For  the  purpose 
the  patient  is  postured  on  the  bed  pan  and  the  anus  and  surround- 
ing tissues  cleansed'  in  the  manner  similar  to  that  employed  about 
the  urethra.  The  nozzle  of  the  syringe  is  gently  pushed  into  the 
bowel,  care  being  taken  to  avoid  unnecessary  contact  with  the  an- 
terior surface  of  the  rectum. 

After  the  bowels  have  moved,  the  anus  and  surrounding  sur- 
face are  again  cleansed  in  the  manner  stated,  and  the  parts  dusted 
with  an  antiseptic  powder.  When  the  anal  outlet  is  being 
cleansed  subsequent  to  the  fecal  expulsion,  the  pledgets  should  be 
wiped  over  the  anus  from  before  backward,  to  avoid  dragging 
feces  toward  or  into  the  wound. 

THE    CARE    OF   THE    WOUND 

The  care  of  the  wound  depends  somewhat  on  the  character  of 
operation  performed.  The  precautions  with  respect  to  cleanli- 
ness as  regards  urination  and  defecation  have  already  been  dis- 
cussed.    All  manipulations  should  be  conducted  with  gentleness, 


528      GYNECOLOGICAL   OPERATIONS   BY  PERINEAL   ROUTE 

and  contact  of  the  fingers  with  the  wound  avoided.  For  the  pur- 
pose cotton  or  gauze  pledgets  held  by  forceps  should  be  em- 
ployed. 

Removal  from  the  perineum  of  stitches  which  emerge  on  the 
skin  may  be  done  on  the  eighth  day.  Those  within  the  vagina 
may  be  left  in  place  until  the  twelfth  day,  as  their  removal  in- 
volves some  trauma  to  the  line  of  union,  and  firm  healing  may 
not  be  expected  until  the  expiration  of  this  time.  With  the  proper 
exercise  of  cleanliness,  as  stated,  sutures  emerging  upon  the 
vaginal  mucosa  may  safely  be  left  in  situ  for  two  weeks.  The  cer- 
vical sutures  may  remain  in  place  for  a  long  time.  Silk-worm 
gut  is  largely  employed  for  the  purpose,  and  this  agent  does  not 
infect  very  readily.  In  any  event,  it  may  be  said  that,  if  the 
perineum  have  been  repaired  simultaneously  with  the  cervix,  the 
sutures  in  the  latter  need  not  be  removed  for  four  weeks  following 
the  operation,  at  which  time  firm  repair  of  the  perineum  has  taken 
place.  For  the  purpose  of  removing  the  stitches  from  the  peri- 
neum the  field  is  cleansed  with  a  solution  of  boric  acid,  which 
will  remove  quite  readily  the  crust  of  exudate  and  powder,  mak- 
ing visible  the  stitches.  This  may  be  repeatedly  done  for  several 
hours  before  the  stitches  are  removed,  the  measure  being  executed 
by  the  nurse.  The  patient  is  then  postured  in  the  Sims  position, 
the  nurse  or  assistant  holds  apart  the  buttocks,  and  the  stitches  are 
removed  in  the  manner  described  above  (page  304). 

In  removing  sutures  from  the  cervix,  the  patient  is  placed  in 
the  Sims  position,  the  posterior  vaginal  wall  retracted  and  the 
cervix  seized  with  a  small  volsellum.  The  stitches  are  seized  with 
forceps  and  removed,  cutting  the  suture  material  near  the  knot. 
This  latter  step,  that  of  removal  of  stitches  from  the  cervix,  should 
be  done  in  a  good  light,  and  an  assistant  should  be  available  to 
hold  the  speculum  and  volsellum. 

After  repair  of  the  wound  the  patient  is  subjected  to  a  general 
tonic  treatment.  In  cases  of  operation  for  plastic  repair,  espe- 
cially where  the  sphincter  ani  has  been  involved,  the  patient's 
mental  status  is  apt  to  be  somewhat  demoralized.  Kelly  regards 
systematic  exercise  with  intervals  of  rest  as  important  in  these 
cases  following  the  operation.  It  is,  no  doubt,  true  that  the  en- 
feebled muscular  tone  of  the  patient  has  some  bearing  in  this  con- 
nection, and  that  measures  directed  toward  improving  the  gen- 


VAGINAL  DRAINAGE   OF   PELVIC   ABSCESS  529 

eral  condition  has  an  influence  with  respect  to  rapid  return  of 
normal  contractility  of  the  muscles  of  the  perineum. 

Indulgence  in  the  sexual  function  should  be  abstained  from 
for  two  months  following  plastic  repair  of  the  vagina.  It  is  dif- 
ficult to  lay  down  a  hard  and  fast  rule  in  this  connection.  It  is, 
however,  probable  that  in  most  instances  complete  repair  is  con- 
served if  this  rule  be  followed. 

Infection  is  manifested  in  this  situation  in  the  same  manner 
as  obtains  elsewhere.  If  infection  occurs  at  the  seat  of  one  of  the 
sutures,  it  should  be  removed  at  once.  Infection  in  the  tissues 
contiguous  to  the  line  of  union  should  be  treated  with  early  in- 
cision and  drainage  with  strands  of  silk-worm  gut.  In  this  way 
extension  of  the  process  may  frequently  be  avoided.  At  times 
abscess  of  one  of  the  glands  of  Bartholin  occurs.  This  is  incised 
early,  for  the  reason  stated.  If  infection  of  the  entire  wound 
occurs,  the  stitches  should  be  removed.  However,  the  deep  su- 
tures of  silk-worm  gut  should  be  kept  in  place  until  the  last ; 
drainage  is  accomplished  at  either  side,  with  the  view  of  obtain- 
ing apposition  by  granulation  healing  when  the  infection  sub- 
sides. In  this  way,  while  a  favorable  cosmetic  effect  will  prob- 
ably not  be  achieved,  sphincteric  control  is  at  times  accomplished, 
and  an  important  factor  in  the  case  is  eliminated. 

VAGINAL   DRAINAGE   OF   PELVIC   ABSCESS 

Vaginal  drainage  of  pelvic  abscess  is  prepared  for,  as  stated 
above  (page  521).  After  the  abscess  is  opened  the  residual  cavity 
is  loosely  packed  with  iodoform  gauze,  a  second  loose  packing  of 
the  same  material  is  introduced  into  the  vagina,  and  a  gauze  pad 


Fig.   330. — Curved  Volsellitm   for  Holding  Cervix   Uteri  during 
Manipulations. 

applied  to  the  vaginal  outlet,  which  is  held  in  place  with  a  T-band- 
age  or  vulvar  pad  (Fig.  3-i4).     The  gauze  packing  in  the  sac  is 


530      GYNECOLOGICAL   OPERATIONS   BY   PERINEAL  ROUTE 

not  disturbed  for  three  or  four  days,  at  the  end  of  which  time  the 
patient  is  placed  in  the  lithotomy  position  (Fig.  324),  the  ex- 
ternal parts  are  cleansed  in  the  usual  manner,  and  the  vaginal 
pack  is  removed.  The  posterior  vaginal  wall  is  retracted  and  the 
cervix  held  forward  by  means  of  a  volsellum  (Fig.  330),  exposing 


Fig.  331. — Stout  Curved  Saw-toothed  Traction  For- 
ceps for  Removing  the  Gauze  Pack.  The  jaws  shown 
in  lower  figure.      {Kelly.) 


the  packing  in  the  sac.  The  latter  is  at  times  left  long  and  ex- 
tends well  into  the  vagina,  making  unnecessary  the  manipulation 
of  the  cervix  at  this  time  in  the  manner  stated. 

The   protruding  gauze   is   seized   with   a   saw-toothed   forceps 
(Fig.  331)   and  withdrawn.     The  cervix  is  now  seized  with  the 


Fig.  332. — Bozeman  Return  Flow  Metal  Irrigating  Tube  Used  for  Cleansing 
Interior  of  Cavities.  The  instrument  may  be  taken  apart  as  indicated  above 
and  cleansed. 

volsellum  in  the  manner  stated  above  and  the  abscess  cavity  irri- 
gated. For  the  purpose,  ample  provision  for  return  of  the  cleans- 
ing fluid  should  be  made,  and  the  vaginal  speculum  should  be 
left  in  situ.  For  the  purpose  of  cleansing  the  abscess  cavity,  the 
metal  intrauterine  return  flow  instrument  shown  in  Fig.  332  will 


VAGINAL  DRAINAGE   OF   PELVIC  ABSCESS  531 

be  found  to  meet  the  indications.  In  the  absence  of  this  instru- 
ment the  Kemp  tube  (Fig.  345)  will  be  found  to  answer  the  pur- 
pose. The  former  discharges  the  return  flow  into  the  vagina  and 
cleanses  it  at  the  same  time,  and  may  be  regarded  as  the  more 
useful  instrument  for  the  purpose.  The  lavage  should  be  pre- 
ceded by  cleansing  of  the  vagina,  and  the  usual  asepsis  should  be 
observed  throughout  the  manipulation,  for  although  an  infected 
cavity  is  being  treated,  the  introduction  of  additional  infection, 
the  character  of  which  may  be  more  virulent  than  the  one  exist- 
ing, should  be  avoided. 

After  the  cavity  is  cleansed  a  fresh  packing  is  introduced  by 
means  of  a  long  dressing  forceps  (Fig.  333).     This  manipulation 


Fig.  333. — Uterine  Dressing  Forceps,   Useful  for  Removing  Gauze 
from   cul-de-sac. 

is  repeated  until  the  discharge  from  the  sac  ceases,  which  requires 
in  uncomplicated  cases  about  two  weeks.  The  patient  is  encour- 
aged to  assume  the  sitting  posture  after  the  first  change  of  the 
packing,  with  the  view  of  promoting  drainage,  and  is  allowed  to 
leave  the  bed  on  the  tenth  day  following  the  operation. 

Fecal  fistula  follows  section  of  the  posterior  vaginal  vault  in 
a  certain  number  of  cases.  The  fact  that  discharge  of  feces  per 
vaginam  does  not,  in  a  large  number  of  cases,  occur  until  the 
fifth  day  or  later  after  the  section,  suggests  that  the  inflammatory 
process  produces  sloughing  of  the  anterior  rectal  wall  and  the 
fistula  is  not  established  until  the  slough  separates.  In  another 
number  of  cases  the  rectum  is  injured  during  the  operative  pro- 
cedure. In  either  event,  the  discharge  of  the  feces  from  the  va- 
gina heralds  the  establishment  of  the  fistula,  and  when  the  pack 
becomes  odoriferous  it  should  be  at  once  removed  and  the  abscess 
cavity  cleansed  in  the  manner  described  above.  After  the  fistula 
is  established  care  must  be  exercised  in  administering  enemas, 

though  the  rectum  should  be  cleansed  daily  by  means  of  the  Kemp 
36 


532      GYNECOLOGICAL   OPERATIONS   BY  PERINEAL  ROUTE 

tube.  The  abscess  cavity  is  cleansed  daily  and  a  gauze  wick  intro- 
duced. Packing  should  not  be  employed,  and  the  vagina  should 
be  douched  twice  daily.  Spontaneous  repair  of  fistulse  in  this 
situation  occurs  in  most  instances,  the  cervix  becoming  adherent 
at  its  site  and  obliterating  the  opening.  Scrupulous  attention  to 
cleanliness  should  be  employed  in  the  manner  indicated  during 
the  healing.  During  the  cleansing  of  the  vagina  a  rectal  specu- 
lum should  be  introduced  through  the  anus,  to  obviate  collection 
of  the  fluid  employed  for  the  purpose  in  that  organ.  During 
lavage  of  the  rectum  the  vagina  should  be  kept  open  with  a  bi- 
valve speculum  to  permit  of  ready  egress  of  the  fluid,  which  may 
enter  the  abscess. cavity  through  the  fistulous  opening. 

VAGINAL  HYSTERECTOMY 

Vaginal  hysterectomy  is  attended  with  control  of  bleeding  by 
either  clamps  or  ligatures.  When  clamps  are  used,  those  ar- 
ranged with  detachable  handles  are  employed,  and  the  blades  left 
in  situ.  The  instruments  are  surrounded  with  an  iodoform  gauze 
roll  which  extends  well  up  into  the  vault  of  the  vagina.  The 
presence  of  the  clamps  and  gauze  makes  a  line  of  communication 
with  the  peritoneum,  a  condition  of  affairs  favorable  to  infection, 
and  the  suggestions  offered  with  respect  to  cleanliness  and  the  care 
of  the  bladder  and  rectum  must  be  thoroughly  executed.  With 
the  view  of  obviating  contamination  of  the  field  with  urine,  a 
retention  catheter  (page  569)  is  placed  in  the  bladder  and  led 
into  a  conveniently  placed  vessel.  Fig.  334  shows  the  clamps 
rolled  in  the  gauze  and  the  retention  catheter  in  situ. 

Patients  who  have  been  subjected  to  vaginal  hysterectomy, 
after  which  clamps  are  left  in  situ,  suffer  considerable  pain,  neces- 
sitating the  administration  of  opiates.  The  anodyne  should  be 
given  in  sufficient  quantity  to  control  the  symptom.  It  is  wise  to 
administer  hypodermically  one-third  of  a  grain  of  morphia  under 
the  skin,  before  narcosis  is  recovered  from,  as  the  restlessnesss 
consequent  to  the  pain,  together  with  the  semi-consciousness,  may 
result  in  disturbance  of  the  clamps.  Administration  of  the  opiate 
should  be  repeated  as  the  indications  present.  Peritoneal  pain  is 
very  severe  and  the  crushing  of  the  broad  ligaments  within  the 
jaws  of  the  clamps  creates  a  condition  of  affairs  which  it  is  easy 


VAGINAL   HYSTERECTOMY 


533 


to  understand  would  provoke  much  suffering.     Defecation  is  not 
likely  to  occur  for  forty-eight  hours,  for  obvious  reasons,  and  the 


Fig.  334. — Hysterectomy  Clamps  Rolled  in  Gauze.     (Kelly  and  Noble.) 


introduction  of  enemata  should  be  carefully  executed  under  asep- 
tic precautions. 

The  catheter  is  changed  for  a  second  sterile  one  at  the  end 


534      GYNECOLOGICAL   OPERATIONS   BY  PERINEAL   ROUTE 

of  twenty-four  hours,  at  which  time  the  bladder  is  lavaged  with 
boric  acid  solution.  At  the  end  of  another  twenty-four  hours  the 
catheter  is  removed,  the  bladder  again  irrigated,  and  the  gauze 
roll  and  clamps  removed. 

For  the  purpose  the  gauze  is  thoroughly  soaked  with  an  anti- 
septic solution  (corrosive  sublimate  1  in  2,000).  The  clamps  will 
be  found  quite  coated  with  secretion  and  rust.  The  intra-abdom- 
inal portions  of  the  clamps  are  in  a  similar  condition,  and  shreds 
of  crushed  tissue  cause  the  blades  to  stick  rather  firmly.  In  re- 
moving the  clamps  this  should  be  borne  in  mind.  After  the 
handles  are  affixed  to  the  blades  the  locks  are  released  without 
making  any  downward  traction.  If  the  portions  of  the  blood- 
vessels obliterated  by  the  pressure  are  torn  away,  bleeding  will 
occur.  After  the  clamps  are  released  portions  of  the  broad  liga- 
ments adhere  to  the  interstices  between  the  serrated  surfaces  of 
the  clamps,  even  after  the  jaws  are  separated.  Downward  trac- 
tion must  not  yet  be  made.  The  clamps  are  slowly  rocked  from 
side  to  side  on  the  arch  of  a  circle,  and  after  this  manipulation 
has  been  several  times  repeated  the  clamp  may  be  withdrawn. 
As  a  rule,  the  highest  clamp  is  removed  first,  permitting  of 
steadying  of  the  ligament  with  the  lower  ones. 

When  these  manipulations  are  performed,  the  patient  should 
be  brought  to  the  edge  of  the  table  or  bed  and  a  good  direct  light 
should  be  available.  At  times  the  clamps  are  removed  while  the 
patient  is  in  bed.  This  is  advised  against,  as  the  position  of  the 
clamps  with  respect  to  the  direction  of  the  body  has  a  tendency 
to  let  the  protruding  portions  of  the  clamps  point  backward,  and 
when  the  handles  are  raised  undue  damage  to  the  stumps  of  the 
ligaments  is  caused.  The  clamps  should  be  released  and  loosened 
at  the  angle  of  their  introduction  with  the  view  of  accomplishing 
the  purpose,  as  stated  above.  When  ligatures  are  employed  for 
the  arrest  of  bleeding  they  are  usually  left  long,  their  ends  being 
allowed  to  just  reach  to  within  the  vaginal  outlet.  The  vaginal 
vault  and  the  space  between  the  broad  ligaments  is  loosely  packed 
with  gauze  and  the  vagina  itself  filled  with  gauze  packing. 

The  gauze  packing  holds  the  rectum,  bladder,  and  intestine 
away  from  the  wound  and  drains  the  operative  field.  The  gauze 
should  be  loosely  introduced,  the  firm  insertion  of  the  packing 
interfering  with  drainage.     However,  when  the  packing  is  insuf- 


VAGINAL   HYSTERECTOMY  535 

ficient  in  quantity,  the  object  with  respect  to  keeping  the  contents 
of  the  abdomen  away  from  the  wound  is  not  attained.  This  is 
true  as  regards  subsequent  dressings,  and  the  introduction  of  the 
gauze  should  be  always  accomplished  with  the  patient  in  the  lith- 
otomy position  and  under  guidance  of  the  eye,  the  vaginal  walls 
being  held  apart  with  a  vaginal  speculum  or  by  means  of  trac- 
tors held  by  an  assistant. 

Evacuation  of  the  bowel  is  allowed  to  occur  on  the  third  day 
after  the  operation.  A  cathartic  is  administered  in  the  evening 
and  the  following  morning  an  enema  of  sterile  water  and  soap 
is  given.  The  latter  act  is,  as  has  already  been  stated,  carried 
out  with  careful  aseptic  technic  and  the  contiguous  surfaces  are 
thoroughly  cleansed  after  the  bowel  is  emptied.  The  discharge 
of  feces  is  made  to  occur  after  the  clamps  are  removed,  and  there 
is  little  danger  of  infection  occurring  at  this  time  from  contami- 
nation with  feces.  However,  the  precautions  mentioned  should 
be  observed. 

When  ligatures  are  employed  the  gauze  packing  in  the  vagina 
need  not  be  disturbed  for  four  or  five  days  after  the  operation, 
and  pain  is  not  so  great  a  factor  in  the  after  care.  If  the  gauze 
packing  in  the  vagina  is  saturated  with  secretions  before  this 
time,  it  should  be  changed.  It  is  best  to  leave  the  gauze  in  situ 
for  the  four  or  five  days,  as  in  this  way  the  contents  of  the  ab- 
domen are  kept  away  from  the  surfaces  of  the  cut  vaginal  vault 
until  a  certain  amount  of  repair  has  taken  place.  Theoretically 
this  lessens  the  dangers  of  postoperative  infection. 

As  a  rule,  a  certain  amount  of  sloughing  of  the  edges  of  the 
sectioned  vagina  and  broad  ligaments  follows  the  operation.  This 
interferes  with  healing,  and  while  the  sloughs  are  separating,  the 
intestine  should  be  kept  from  coining  in  contact  with  the  wound 
surfaces  in  the  manner  stated.  Repair  of  the  vaginal  vault  does 
not,  at  times,  occur  until  weeks  after  the  operation.  If  the  repair 
is  permitted  to  go  on  without  guidance,  a  loop  of  small  intestine 
partially  prolapses  into  the  space  at  the  vault  of  the  vagina  in 
some  instances,  and  becomes  adherent  in  this  situation.  The 
writer  has  seen  cases  of  this  sort,  and  in  each  instance  celiotomy 
and  suprapubic  repair  of  the  vaginal  vault  was  made  after  the 
intestine  has  been  loosened.  The  latter  step  was  regarded  as 
dangerous  when  attempted  from  the  vagina.     The  ultimate  repair 


536      GYNECOLOGICAL    OPERATIONS    BY   PERINEAL  ROUTE 


contemplates  repair  of  the  vaginal  vault  with  the  rectum  and 
bladder  forming  the  dome  above  the  vaginal  scar.  With  this  in 
view,  the  parts  should  be  manipulated  at  each  dressing,  making 
smaller  and  smaller  the  tamponade  until  healing  is  complete. 


Fig.  335. — Appearance  of  Vaginal  Vault  after  Vaginal  Hysterectomy.      Vault 
of  Vagina  Held  in  Place  with  Stitch.     (Kelly.) 

At  times  a  stitch  is  taken  in  the  center  of  the  vaginal  vault 
holding  together  the  peritoneum  (Fig.  335).  This  obviates,  to 
a  certain  extent,  the  contingency  related  above,  holding  away 
from  the  vagina]  vault  the  small  intestine.     In  these  instances  the 


VAGINAL  HYSTERECTOMY  537 

packing  is  introduced  on  either  side  of  the  stitch,  and  the  rest  of 
the  local  after-treatment  executed  in  the  manner  stated  above. 

During  the  after-treatment,  douching  of  the  vagina  is  per- 
missible, but  should  be  performed  when  the  patient  is  on  the 
table,  as  described,  and  the  cleansing  made  through  a  speculum 
to  avoid  the  carrying  of  infection  into  the  peritoneum.  At  times 
shreds  of  sloughing  tissue  may  be  removed  with  the  dressing 
forceps.  On  the  whole,  the  after  care  following  vaginal  hysterec- 
tomy is  attended  with  considerable  labor,  and  should  be  patiently 
carried  out. 

When  infection  occurs,  following  either  the  use  of  clamps  or 
ligatures,  the  case  is  treated  in  the  manner  in  which  infection  is 
taken  care  of  elsewhere. 

Fecal  or  urinary  fistulae  follow  vaginal  hysterectomy  in  a  small 
percentage  of  cases.  In  some  instances  sloughing  extends  into 
either  the  rectum  or  bladder.  If  this  occur,  the  packing  must  be 
changed  daily  and  the  parts  cleansed  very  thoroughly  at  each 
sitting. 

Enemata  are  given  under  the  precautions  described  in  con- 
nection with  drainage  of  pelvic  abscesses  (page  531).  The 
bladder  is  kept  clean,  and  if  the  fistula  into  this  organ  is  consid- 
erable in  size  a  retention  catheter  may  be  introduced  into  the 
bladder  (Fig.  336)  and  the  latter  is  taken  care  of  as  stated  (page 
533). 

Cystitis  follows  vaginal  section  by  the  perineal  route  in  a  cer- 
tain number  of  cases.  Ordinarily,  acute  cystitis  with  pus,  mu- 
cus and  blood  in  the  urine,  subsequent  to  the  operation,  will 
subside  under  mild  treatment  without  the  necessity  of  local  treat- 
ment. The  pain  and  tenesmus  are  frequently  relieved  by  the  ad- 
ministration of 

3?      Kali   citrat 4  drachms 

Tr.  hyscyomi 6  drachms 

Elix.  simpl q.  s.  ad  6  ounces 

S.   Tablespoonful  every  two  to  three  hours  in  water. 

When  the  more  acute  symptoms  subside,  urotropin  in  five- 
grain  doses  may  be  given  and  the  anodyne  mixture  administered 
at  night. 


538       GYNECOLOGICAL   OPERATIONS    BY   PERINEAL   ROUTE 


If  pus  is  persistently  present,  irrigation  of  the  bladder  with 
boric  acid  solution  may  be  made  once  daily.  For  the  purpose  a 
"  two-way  "  catheter  may  be  used,  the  upper  connection  being  at- 
tached to  a  long  rubber  tube  connected  with  a  funnel.     To  the  lower 


outlet  is  attached  a  rubber  tube  draining  off  the  fluid. 


Fig.  336 


Fig.  336. — Irrigation  of  Bladder  with  "  Two-way  "  Catheter.     (Kelly.) 


shows  the  apparatus  in  use.  Care  must  be  exercised  not  to  permit 
the  funnel  to  become  empty  during  the  manipulations,  or  air  will 
be  sucked  into  the  bladder  by  the  entering  column  of  water  and 
distressing  tenesmus  is  provoked.  The  advantage  the  method 
has  over  the  use  of  the  irrigator  or  syringe  is  that  the  pressure 
is  easily  regulated  by  the  elevation  of  the  funnel,  and  this  should 


VAGINAL   HYSTERECTOMY  539 

not  be  held  higher  than  will  provoke  a  moderately  rapid  flow  of 
cleansing  fluid  into  the  bladder.  By  lowering  the  funnel  to  be- 
low the  level  of  the  bladder  the  contents  can  be  siphoned  off. 

The  measures  related  above  usually  achieve  the  purpose  in  a 
few  days.  However,  in  a  certain  number  of  cases  the  symptoms 
persist,  and,  indeed,  chronic  ulcerative  cystitis  has  occurred  under 
the  conditions  mentioned. 


Fig.  337. — Method  of  Continuous  Irrigation  of  Bladder  with  Patient  in  Bed 
on  Bed  Pan.     {Kelly.) 

Kelly  employs  in  these  cases  irrigation  of  the  bladder,  as 
stated,  using  a  solution  of  nitrate  of  silver  (1-1,000)  for  the  pur- 
pose. A  small  quantity  of  the  solution  (4  ounces)  is  left  in  the 
bladder  to  be  voided  at  the  next  urination.  In  very  obstinate 
cases,  where  ulceration  is  present,  Kelly  subjects  the  bladder  to 
continuous  irrigation  with  a  warm  boric  acid  solution.     The  pa- 


540      GYNECOLOGICAL   OPERATIONS  BY  PERINEAL  ROUTE 

tient  is  postured  as  shown  in  Fig.  337.  A  double  soft  rubber 
catheter  (Fig.  336)  is  introduced  through  the  urethra  into  the 
bladder,  and  held  in  place  with  a  perineal  pad  fastened  with  a 
tape  around  the  waist.  The  upper  catheter  is  connected  with  an 
irrigator,  as  shown  in  the  illustration,  the  lower  one  is  led  into 
a  pan,  and  the  latter  drains  into  a  jar,  as  shown  in  Fig.  337.  The 
irrigation  may  be  maintained  for  several  hours  at  a  time,  at  the 
end  of  which  time  the  irrigating  tube  is  disconnected  and  the 
bladder  emptied.  An  instillation  of  nitrate  of  silver  solution,  as 
stated  above,  is  introduced  into  the  bladder.  Exceedingly  ob- 
stinate cases  of  infection  of  the  bladder  will  yield  to  this  form  of 
treatment. 


CHAPTEK    XXVIII 
OPERATIONS  ON  THE   RECTUM   AND  ANUS 

Operations  on  the  rectum  by  the  sacral  route — Operations  on  anus  and  rectum 
by  the  perineal  route — Fistula  in  ano — Removal  of  hemorrhoids — Prolapse 
of  rectum,  perineal  proctectomy,  from  the  rectum  and  excision  of  tumors. 


When  the  rectum  is  approached  by  the  transperitoneal  route, 
the  preparation  of  the  patient  and  subsequent  care  and  treatment 
do  not  differ  from  those  described  above  in  connection  with  celi- 
otomy and  invasion  of  the  gut.     Manipulations  about  the  rectum 


Fig.  338. — Tuttle's  Pneumatic  Proctoscope.  (Tuttle.)  A,  obturator;  B, 
plug  with  glass  window  for  closing  tube;  C,  handle;  D,  cords  connect- 
ing instrument  with  battery  or  street  current;  E,  inflating  bulb;  F, 
main  tube  of  proctoscope. 

in  postoperative  cases  will  be  found  greatly  facilitated  by  em- 
ploying the  outfit  shown  in  Fig.  338.     Facilities  for  the  necessary 

541 


542 


OPERATIONS   ON   THE  RECTUM  AND   ANUS 


If 


electric  energy  are  not  at  all  times  available.  Under  these  cir- 
cumstances the  outfit  shown  in  Fig.  342  will  be  found  to  meet 
the  indication,  though  perhaps  with  less  comfort  to  the  surgeon 
than  that  shown  in  Fig.  338.  The  outfit  shown  in  Fig.  338  has 
the  advantage  of  permitting  of  inspection  and  treatment  of  con- 
ditions in  the  rectum  without  the  use  of  in- 
direct light.  In  addition  to  this,  the  forceps 
shown  in  Fig.  339  will  be  found  a  useful 
addition  to  the  armamentarium,  especially 
in  cleansing  the  rectal  wound  with  gauze  or 
cotton  wipes.  The  forceps  has  the  lock  ar- 
ranged in  such  a  manner  as  to  permit  of 
opening  and  shutting  in  a  small  space. 

OPERATIONS  ON  THE  RECTUM  BY 
THE  SACRAL  ROUTE 

Operations  of  this  sort  usually  involve 
much  trauma  and  consequently  are  fre- 
quently attended  with  considerable  shock. 
Ample  provision  should  be  made  to  meet 
the  indications  in  this  regard  (page  229). 
The  administration  of  nutritive  constitu- 
te. 339. Alligator    ents  and  stimulants  by  rectum,  following 

Forceps  for  Cleansing    operations  in  this  situation,  is,  of  course, 

Wound      of      Rectum.  .  .  „, 

(Tuttle.)  attended  with  some  difficulty,  though  enter- 

oclysis  may  be  employed,  provided  the 
solution  is  rendered  sterile  and  asepsis  be  conserved  during  the 
administration. 

Extirpation  of  the  rectum  by  the  sacral  route,  when  it  is  pos- 
sible to  maintain  the  anal  outlet  in  the  normal  position,  is  less 
likely  to  be  followed  by  infection  than  when  an  artificial  anus  is 
made  in  the  wound. 

Fig.  340  shows  the  appearance  of  the  wound  and  anus  in  the 
class  of  cases  where  the  anus  is  left  intact.  Drainage  of  the 
wound  is  employed  to  lead  off  any  leakage  which  may  occur  at 
the  seat  of  rectal  trauma,  and,  also,  as  this  method  of  attacking 
the  rectum  involves  the  fashioning  of  a  bone  flap,  to  permit  of 
the  exit  of  secretions  from  the  surfaces  of  the  sectioned  bone.     A 


OPERATIONS   ON   THE   RECTUM   BY  THE  SACRAL   ROUTE     543 

certain  amount  of  necrosis  of  the  bone  occurs  in  most  instances, 
and  the  drainage  opening  will  permit  of  discharge  of  the  sepa- 
rated particles  of  bone  tissue.  It  will  be  seen  by  the  illustration 
that  a  rubber  tube  of  considerable  caliber  is  introduced  into  the 


Fig.  340. — Appearance  of  Wound  after  Excision  of  Rectum  by  the  Sacral 
Route.  G,  Gauze  draining  retro-rectal  space ;  T ,  Tampon  and  drainage  tube  in 
anus.      {T  utile.) 


rectum  through  the  anus,  which  is  surrounded  with  gauze,  and 
serves  the  purpose  of  permitting  of  easy  expulsion  of  gas  and 
discharge  of  secretions.  Distention  of  the  rectum  and  sigmoid 
following  this  class  of  operations  is  exceedingly  distressing  to  the 
patient  and  interferes  with  ready  repair  of  the  wound  in  the  gut. 
The  drainage  tube  also  gives  an  avenue  of  egress  to  the  secretions 
from  the  wound  in  the  gut. 

The  rubber  tube  should  be  fenestrated  (Fig.  14-'> )  and  be  passed 
beyond  the  line  of  union  in  the  gut.  The  distal  portion  of  the 
tube  may  be  connected  with  a  long  flexible  tube,  which  is  led  into 
an  appropriate  receptacle  described  under  colectomy  (page  505). 
When  the  nature  of  the  affliction  for  the  relief  of  which  rectal 


544 


OPERATIONS   ON  THE   RECTUM   AND   ANUS 


extirpation  has  been  undertaken  makes  maintenance  of  the  nor- 
mal site  of  fecal  discharge  impossible,  the  proximal  end  of  the 
gnt  is  sutured  into  the  wound  in  the  manner  shown  in  Fig.  341. 


Fig.  341. 


-Appearance  of  Artificial  Anus  After  Sacral  Resection  of  Rectum. 
(Tuttle.)     A,  Artificial  amis;   G,  Gauze  drain. 


While  the  protective  dressing  need  not  be  changed  for  several 
days  following  the  operation  where  the  normal  outlet  for  feces  is 
maintained,  the  wound  must  be  dressed  daily  or  more  often  when 
an  artificial  anus  is  made. 

In  either  event  the  bowel  is  quieted  with  an  opiate,  and  no 
catharsis  is  provoked  for  four  or  five  days  following  the  opera- 
tion, with  the  view  of  lessening  the  dangers  of  infection  from  feces. 
The  postoperative  diet  should  be  bland  and  contain  no  substances 
which  leave  large  residuum  for  expulsion  by  the  rectum.  The 
precautions  taken  up  under  the  general  head  of  intestinal  opera- 
tions should  be  observed. 

When  finally  catharsis  is  employed,  a  saturated  solution  of 
magnesium  sulphate  in  doses  of  one  drachm  every  hour  will  re- 
sult in  catharsis  in  about  five  hours  after  beginning  of  the  dosage. 


OPERATIONS   ON   THE   RECTUM   BY  THE  SACRAL   ROUTE     545 

Two  hours  after  beginning  of  the  medication  four  ounces  of 
sterile  olive  oil  warmed  to  the  temperature  of  105°  F.  are  gently 
injected  into  the  bowel  either  through  the  drainage  tube  or  arti- 
ficial anus.  One  hour  later,  a  half  pint  of  a  solution  of  sodium 
carbonate  2  per  cent,  is  injected  in  the  same  way.  Cleansing  of 
the  bowel  in  this  manner  is  attained  thus  with  but  little  disturb- 
ance to  the  patient.  The  catharsis  should  be  so  arranged  as  to  have 
the  ultimate  outcome  occur  at  a  time  when  cleansing  of  the 
wound,  which  should  be  done  soon  after  the  bowel  is  emptied,  is 
made  by  the  attendant.  In  the  event  of  a  spontaneous  discharge 
of  feces  before  this  time,  or  if  the  surgeon  is  not  promptly  avail- 
able when  the  discharge  of  feces  occurs,  the  nurse  should  remove 
the  dressing  and  cover  the  wound  with  a  wet  antiseptic  dressing 
until  the  proper  dressing  is  applied. 

The  superficial  drain  may  be  removed  on  the  fifth  day  if  no 
infection  have  occurred.  If  the  wound  is  contaminated,  it  is 
treated  along  the  lines  stated  above  in  this  connection.  The 
wound  shown  in  the  illustration  is  closed  with  a  continuous  su- 
ture. The  writer  employs  interrupted  silk-worm  gut  sutures  for 
the  purpose,  for  the  reasons  already  stated.  When  catgut  is  used 
the  sutures  need  not  necessarily  be  removed.  When,  however, 
silk-worm  gut  is  used,  the  sutures  are  removed  on  the  tenth  day 
following  the  operation. 

Following  the  primary  dressing  of  the  wound,  that  is,  after 
the  first  evacuation  of  feces,  the  drainage  tube  and  gauze  plug- 
need  not  necessarily  be  reinserted.  If,  however,  the  superficial 
or  sacral  wound  show  evidence  of  infection  at  this  time,  the  drain- 
age had  best  be  reintroduced,  with  the  view  of  draining  any  in- 
fective secretions  which  may  find  their  way  from  the  retrorectal 
space  into  the  bowel.  If  this  contingency  occur,  the  rectum  must 
be  cleansed  daily,  using  the  Kemp  (Fig.  345)  tube,  or  the  anus 
is  distended  with  a  speculum  and  the  site  of  the  wound  in  the 
bowel  thoroughly  cleansed  under  guidance  of  the  eye.  The  latter 
plan  is  the  better.  However,  in  some  instances  the  anus  is  in- 
flamed and  sensitive  as  the  outcome  of  manipulations  in  this 
situation,  and  the  Kemp  tube  may  be  advantageously  used  for  the 
purpose. 

The  rectum  is  quite  intolerant  of  strong  antiseptic  solutions. 
For  the  purpose  of  cleansing  the  wound  a  saturated  (sterile)  so- 


Fig.  342. — Kelly's  Set  of  Instruments  for  Treatment  of  Wounds  of  Rectum 
and  Sigmoid.  A,  Sponge-holder;  B,  Applicator;  C,  Curette;  D,  Anal  dilator; 
E,  Anoscope;  F,  G,  H,  Protoscopes.     (Tuttle.) 


546 


OPERATIONS   ON  THE  RECTUM   BY  THE  SACRAL  ROUTE     547 

lution  of  boric  acid  may  be  used.  The  solution  is  introduced  into 
the  rectum  under  very  slight  pressure  when  the  Kemp  tube  is 
used,  and,  of  course,  need  not  cause  any  disturbance  whatever 
when  the  manipulations  are  carried  on  through  a  speculum. 

For  the  purpose  the  instruments  shown  in  Fig.  342  will  be 
found  very  useful.  The  length  of  the  speculum  selected  for  a 
given  case  depends  upon  the  distance  from  the  anus  at  which 
union  of  the  divided  ends  of  the  gut  has  been  made.  It  will  be 
found  expedient  to  dilate  carefully  the  anus  with  the  conical  di- 
lator (d)  shown  in  the  illustration.  The  introduction  of  the 
cylindrical  speculum  is  attended  with  very  little  pain,  and  when 
the  rectum  is  thus  distended  cleansing  of  the  parts  may  be  thor- 
oughly and  efficiently  made.  At  times  a  small  area  of  mucosa 
at  the  site  of  union  sloughs.  This  may  be  removed  by  using  the 
curette  shown  in  the  illustration  (c).  Collections  of  pus  may  be 
wiped  away  with  a  gauze  pledget  held  in  the  jaws  of  the  sponge 
holder  (a).  Applications  of  tincture  of  iodin,  pure  carbolic  acid 
or  a  solution  of  nitrate  of  silver,  60  grains  to  the  ounce,  may  be 
made  at  the  site  of  the  wound  by  means  of  cotton  wound  on  the 
applicator  (b). 

Wounds  in  the  rectum  may  in  this  manner  be  treated  in  the 
same  way  as  are  wounds  more  superficially  located.  The  treat- 
ment is  carried  on  until  healing  is  complete,  which  in  this  situa- 
tion may  require  three  or  four  weeks. 

The  daily  introduction  of  a  speculum  into  the  rectum  will  be 
found  quite  distressing,  and,  indeed,  after  four  or  five  days  fol- 
lowing the  operation,  complete  cleansing  of  the  wound  need  only 
be  made  upon  each  alternate  day.  For  the  purpose  of  cleansing 
and  treating  the  rectum,  the  "  knee-chest  "  position  will  be  found 
to  serve  best  the  conditions  (Fig.  343).  In  this  position  the 
weight  of  the  abdominal  organs  is  taken  entirely  off  the  rectum, 
and  the  dilating  effect  of  atmospheric  pressure  is  attained.  This 
position  is  very  useful  after  convalescence  has  been  established 
and  the  need  of  irrigation  no  longer  obtains,  the  cleansing  of  the 
part  being  achieved  by  sponges  soaked  with  a  cleansing  fluid.  In 
the  event  of  considerable  infection  being  present,  and  when  lib- 
eral lavage  of  the  surface  is  regarded  necessary,  the  patient  had 
best  be  placed  in  the  Sims  (Fig.  346)  or  lithotomy  position. 

When  the  Sims  position  is  used,  the  irrigation  should  be  made 
37 


548 


OPERATIONS   ON   THE   RECTUM   AND   ANUS 


through  a  return  flow  tube  (Fig.  346),  as  the  posture  does  not 
allow  of  proper  drainage  of  the  cleansing  fluid,  unless  some  spe- 
cial provision  be  made.     When  the  irrigation  is  used  through  the 


Fig.  343. — Knee-chest  Position  for  Approaching  Wound  after  Resection  of 

the  Rectum.     (T utile.) 

speculum,  the  lithotomy  position  will  be  found  to  meet  best  the 
indications. 

In  cases  in  which  an  artificial  anus  is  made,  the  patient  is 
fitted  with  a  pad  and  abdominal  band  similar  to  that  worn  after 
colostomy  (Fig.  317). 


OPERATIONS  ON  THE  ANUS  AND  THE  RECTUM  BY  THE 
PERINEAL  ROUTE 

Operations  in  this  situation  present  the  problem  of  achieving 
asepsis  under  rather  unfavorable  conditions.  It  is  probable  that 
despite  cleanliness,  as  generally  understood  in  making  the  toilet, 
a  certain  amount  of  infective  bacteria  inhabit  the  hair  follicles 
contiguous  to  the  anus  and  in  the  skin  of  perineum  at  all  times, 


OPERATIONS  ON  ANUS  AND  RECTUM  BY  PERINEAL  ROUTE    549 

and  that  they  exist  in  this  situation  in  greater  numbers  than  ob- 
tains in  other  portions  of  the  bod)' . 

The  hair,  too,  in  this  situation  is  likely  to  be  abundant,  and 
this  contributes  to  the  difficulties  as  regards  cleanliness.  It  is 
wise  to  apply  the  measures  laid  down  with  the  view  of  cleansing 
the  skin  in  this  situation  with  exactness.  The  parts  had  best  be 
shaved  several  days  before  the  operation,  and,  if  a  short  growth 
of  hair  has  appeared  at  the  time  of  final  preparation,  the  razor 
should  be  again  employed,  and  this  supplemented  with  copious 
application  of  soap  and  prolonged  lavage. 

With  regard  to  catharsis,  it  would  seem  best  that  the  bowels 
should  not  be  moved  by  medication  for  twenty-four  hours  before 
the  operation  and  cleansing  of  the  rectum  and  sigmoid  be  achieved 
with  enemata.  For  the  purpose  an  enema  of  soap  and  water  may 
be  given  twelve  hours  before  the  operation,  and  six  hours  later 
another  of  acetozone,  1  in  1,000,  may  be  given.  !No  liquid  should 
be  introduced  into  the  rectum  after  this,  as  it  may  not  be  entirely 
expelled  by  the  time  the  operation  is  performed,  as  the  discharge 
of  the  residual  amount  of  liquid,  together  with  some  feces,  is 
likely  to  occur  as  the  patient  struggles  while  being  narcotized. 
This  latter  occurrence  is  exceedingly  disagreeable,  and  is  likely  to 
fertilize  the  operative  field.  If  there  be  any  doubt  as  to  the  lower 
bowel  being  empty,  a  sterile  rubber  tube  of  considerable  caliber 
may  be  passed  into  the  rectum  and  final  discharge  of  fluids  en- 
couraged just  before  the  operation  and  immediately  before  the 
final  cleansing  of  the  operative  field,  when  the  patient  is  on  the 
operating  table. 

However,  accidental  discharge  of  fluid  from  the  rectum  does 
at  times  occur  during  the  operation,  and  it  is  wise  to  have  at  hand 
a  duplicate  set  of  the  necessary  instruments,  and  when  soiling  of 
the  operative  field  occurs,  these  may  be  made  to  replace  those  con- 
taminated. 

Also,  provision  should  be  made  for  a  second  cleansing  of  the 
operative  field,  which  is  done  by  an  assistant  while  the  surgeon 
cleanses  himself  and  changes  his  gown.  In  this  class  of  cases  the 
wearing  of  gloves  is  quite  essential,  for  if  soiling  occurs  it  is  not 
attended  with  as  much  damage  as  when  the  infective  material 
comes  in  contact  with  the  skin,  and  it  is,  of  course,  a  simple  mat- 
ter to  remove  the  soiled  gloves  and  replace  them  with  sterile  ones. 


550  OPERATIONS    OX   THE   RECTUM   AND    AXES 

During  operations  of  this  kind  the  patient  is  usually  placed 
in  the  lithotomy  position  and  the  operative  field  isolated,  the  ar- 
rangement in  this  regard  being  quite  similar  to  that  employed  in 
gynecological  operations,  and  is  described  under  that  head  (Fig. 
324),  except,  of  course,  that  the  anus  is  not  covered  with  a  sterile 
towel,  as  obtains  with  that  class  of  cases. 

The  towel  is  lowered  so  as  to  make  accessible  the  anus  and, 
at  the  same  time,  obviate  contact  with  non-sterile  surfaces  by  the 
hands  and  instruments.  At  times  the  lateral  Sims  position  is 
employed  (Fig.  346).  However,  better  drainage  and  greater  ac- 
cessibility is  attained  by  the  lithotomy  position,  unless  the  opera- 
tive procedure  contemplates  attack  on  the  sacrum,  in  which  event 
the  Sims  position  is  preferable. 

FISTULA   IN   ANO 

Fistula  in  ano,  for  which  operative  relief  is  undertaken,  in- 
volves in  preparation  for  surgical  attack  the  question  of  the  char- 
acter of  pathological  process.  A  sufficient  number  of  patients  af- 
flicted with  fistula  in  this  situation  are  tuberculous,  to  warrant 
the  precautions  being  taken  discussed  under  the  head  of  tubercu- 
losis in  general,  and  its  bearing  on  operative  procedure  (page 
11).  In  any  event,  a  search  should  be  made  for  the  avenue  of 
infection,  and  if  this  be  the  lungs  or  the  digestive  tract,  the  pa- 
tient should  be  treated  in  advance  with  the  view  of  obviating 
postoperative  exacerbation  of  the  distal  focus  of  the  tuberculous 
process.  In  any  event,  chloroform  narcosis  should  be  employed 
in  preference  to  that  of  ether,  for  reasons  already  stated.  In  a 
certain  number  of  cases  an  attempt  is  made  to  attain  primary 
union  of  the  wound  after  the  fistulous  tract  has  been  excised.  In 
this  event  the  postoperative  treatment  of  the  wound  does  not  dif- 
fer from  that  employed  when  immediate  union  of  a  wound  is  at- 
tempted elsewhere.  The  bowel  is  kept  quiet  with  opiates,  as  al- 
ready stated,  and  provision  made  for  the  escape  of  flatus  and 
feces,  as  described  above  (page  543). 

In  the  vast  majority  of  instances  no  attempt  at  primary  union 
is  made,  and  the  wound  is  packed  with  gauze  with  the  view  of  at- 
taining repair  by  granulation.  .  In  these  cases  the  same  precau- 
tions with  respect  to  keeping  quiet  the  bowel,  etc.,  should  be  ob- 


FISTULA  IN   ANO  551 

served,  and  at  the  end  of  forty-eight  hours  the  packing  is  removed 
and  replaced  daily  until  repair  ultimately  takes  place.  When  the 
wound  is  dressed,  the  gauze  is  loosened  with  hydrogen  peroxid, 
and  the  line  of  incision  thoroughly  cleansed  with  a  solution  of 
corrosive  sublimate,  1  in  1,000,  or  acidi  carbolici,  1  in  200. 

For  the  purpose  the  patient  is  postured  on  the  bed  pan  or 
similar  device  which  allows  of  prolonged  irrigation.  Sphinteric 
control  is  not  usually  attained  for  a  week  following  the  operation, 
and  the  nurse  should  be  instructed  to  give  an  enema  two  hours  be- 
fore the  contemplated  visit  of  the  surgeon,  and,  after  the  bowels 
have  discharged  their  contents,  to  place  in  contact  with  the  anus 
a  wet  dressing  of  gauze  saturated  with  corrosive  sublimate  solu- 
tion, 1  in  1,000,  until  the  attendant  arrives,  who  then  packs  again 
the  wound  with  gauze  and  applies  the  protective  dressing.  Ca- 
tharsis which  results  in  liquid  stools  should  be  avoided,  unless 
there  be  an  especial  indication  for  the  same. 

As  already  stated,  the  number  of  cases  in  which  the  fistulse 
are  tuberculous  in  origin  is  quite  large,  and  as  these  cases  do  not 
react  readily  after  operative  attack  when  confined  to  bed,  it  is 
advised  that  as  soon  as  the  immediate  eifects  of  the  operation  are 
recovered  from,  the  patient  be  allowed  to  leave  the  bed  and  be 
placed  in  the  open  air.  A  prolonged  convalescence  will  not  in- 
frequently be  obviated,  if  the  patient  be  subjected  to  over-feed- 
ing and  the  care  given  cases  of  tuberculosis  generally.  The  post- 
operative care  of  these  cases  is  exceedingly  trying,  and  both  the 
patient  and  attendant  frequently  become  discouraged.  It  should 
be  borne  in  mind  that  an  ultimate  favorable  outcome  is  the  re- 
ward of  persistent  attention  to  detail,  and  that  neglect  to  guide 
the  healing  along  proper  lines  may  result  in  failure.  For  this 
reason  the  packing  should  be  carefully  and  accurately  introduced 
into  the  wound  at  each  dressing. 

It  is  not  uncommon  for  cases  to  require  six  or  eight  weeks  of 
patient  attention  to  the  suggestions  offered  above  before  complete 
repair  takes  place.  Intelligent  cooperation  on  part,  of  the  patient 
is  an  important  determining  factor.  With  a  little  care,  the  evacu- 
ation of  the  bowels  may  be  made  to  take  place  early  in  the  morn- 
ing, after  breakfast,  and  the  patient  may  then  cleanse  the  anus 
with  a  solution  of  corrosive  sublimate,  1  in  1,000,  and  as  the 
gauze  packing  is  usually  displaced  by  the  action  of  the  sphincter 


552 


OPERATIONS    ON   THE   RECTUM   AND   ANUS 


during  defecation,  a  gauze  pad  may  be  gently  inserted  between 
the  buttocks  by  the  patient  and  held  in  place  with  a  T-bandage 
(Fig.  344).     He  then  journeys  to  the  physician's  office,  who  re- 


Fig.  344. — T-bandage  in  situ.     (Gerster.) 

packs  the  wound  and  applies  the  protective  dressing.  While  the 
practitioner  need  not  feel  that  a  failure  at  relief  is  necessarily  the 
outcome  of  disregard  of  details,  it  may  be  said  that  failure  is  less 
likely  to  occur  if  they  be  assiduously  carried  out. 


REMOVAL   OF   HEMORRHOIDS 

The  removal  of  hemorrhoids  is  preceded  by  the  same  prepara- 
tion as  obtain  with  other  operations  about  the  anus  (page  548), 
including  the  precautions  with  respect  to  cleanliness  before,  dur- 
ing, and  after  the  operation. 

In  the  after-treatment  no  special  measures  will  be  found  neces- 
sary, except,  perhaps,  that  the  pain  and  tenesmus  which  follows 
the  operation  is  more  likely  to  occur  following  this  operation 
than  obtains  in  instances  where  the  sphincter  muscle  is  divided. 
The  dosage  of  opiate  may  have  to  be  somewhat  larger  for  this 
reason,  and  the  use  of  cathartics  take  the  place  of  enemata  for 
the  same  reason. 


REMOVAL   OF   HEMORRHOIDS  553 

As  a  general  rule,  considering  the  thorough  cleansing  given 
the  lower  bowel  immediately  preceding  the  operation,  no  effort 
need  be  made  to  provoke  catharsis  until  the  fifth  day  following 
the  operation  and  the  discharge  of  feces,  when  heralded  by  a  de- 
sire to  defecate  may  be  preceded  by  removal  of  the  gauze  tampon 
and  tube  (Fig.  340),  in  order  to  facilitate  matters,  and  be  fol- 
lowed by  cleansing  of  the  wound  and  reapplication  of  a  protective 
dressing.  The  tamponade  and  tube  need  not  be  reintroduced  at 
this  sitting.  However,  if  distention  with  gas  and  consequent  dis- 
comfort occur,  a  sterile  rubber  tube,  well  covered  with  sterile 
lubricant,  may  be  gently  passed  into  the  rectum  and  left  in  situ 
until  relief  is  obtained. 

During  the  week  succeeding  the  operation,  the  diet  should  be 
restricted  to  milk,  eggs,  broths  and  lean  meats,  though,  of  course, 
these  are  not  given  until  postoperative  vomiting  has  ceased. 

The  period  of  confinement  after  the  operation  depends  to  some 
extent  upon  the  method  of  removal  of  the  pile  employed.  If  the 
ligature  method  has  been  used,  the  patient  should  be  kept  in  bed 
until  the  ligatures  are  either  absorbed  or  come  away.  When 
granulation  is  established  the  patient  may  leave  the  bed,  but  care 
in  cleanliness  should  be  exercised  until  repair  is  complete.  The 
clamp  and  cautery  operation  is  regarded  as  necessitating  confine- 
ment for  only  three  days.  This  is  assumed  on  the  ground  that 
the  cautery  eliminates  the  danger'  of  infection.  This  is  probably 
true  as  regards  the  operation  itself.  However,  the  slough  sepa- 
rates finally,  and  the  resultant  raw  surface  is  susceptible  to  the 
invasion  of  infection  and  should  be  treated  accordingly.  On  the 
whole,  irrespective  of  the  method  of  excision  or  removal  of  piles 
employed,  the  patient  should  be  kept  quiet  until  granulation  is 
established  and  be  under  the  care  of  the  practitioner  who  employs 
the  necessary  cleanliness  until  repair  is  complete.  It  is  not  im- 
probable that  the  abscesses  and  at  times  fistula?  which  occur  as 
sequels  to  operations  for  hemorrhoids,  will  be,  in  a  measure,  pre- 
vented by  exercise  of  caution  in  these  respects. 

Infection  of  the  wound  is  treated  as  are  infected  wounds  else- 
where in  the  body.  However,  it  must  be  remembered  that  piles 
are  varicosities  of  blood-vessels  which  communicate  quite  directly 
with  the  large  venous  trunks  of  the  portal  system,  and  that  a 
septic  phlebitis  in  this  situation  is  a  menacing  occurrence.     Early 


554  OPERATIONS   ON  THE  RECTUM   AND   ANUS 

incision  and  drainage  of  infected  area  should  be  practiced  and, 
if  necessary,  this  should  be  given  the  same  consideration  with  re- 
gard to  the  precautions  employed  in  the  primary  operation. 

A  chill  and  sudden  rise  of  temperature,  together  with  the  other 
symptoms  of  infection,  occurring  several  days  after  attack  upon 
the  veins  of  the  rectum  and  anus,  should  be  followed  at  once  by 
dilatation  of  the  anus  and  search  for  the  offending  area.  If  a 
black  thrombotic  area  is  disclosed  at  the  site  of  operation,  free  in- 
cision, cleansing,  the  application  of  carbolic  acid  and  the  intro- 
duction of  drainage  should  be  employed.  If  necessary,  the  pa- 
tient should  be  completely  narcotized  and  the  manipulations 
thoroughly  carried  out.  A  policy  of  hesitation  may  be  followed 
by  a  septic  infection  of  the  veins  of  the  liver  and  death,  a  con- 
tingency the  writer  had  the  misfortune  to  be  confronted  with  in 
one  instance. 

PROLAPSE    OF    RECTUM,    PERINEAL    PROTECTOMY,    AND 
EXCISION   OF   TUMORS   FROM   THE   RECTUM 

These  operations  all  contemplate  preparations  for  operation 
and  after-treatment,  as  indicated  above.  The  special  measures 
following  operations  for  prolapse  involve  elevation  of  the  foot  of 
the  bed  for  several  days  after  the  operation  and  the  avoidance  of 
tenesmus.  The  latter  is  controlled  by  the  use  of  anodynes,  as  dis- 
cussed on  page  552. 

In  this  connection  the  cleansing  of  the  rectum  by  return  irri- 
gation through  the  undilated  sphincter,  a  measure  frequently  em- 


Fig.  345. — Kemp  Tube  for  Lavage  of  Rectum. 

ployed  following  attack  of  the  interior  of  the  rectum,  may  be 
taken  up.  For  the  purpose  the  Kemp  tube  is  of  signal  service 
(Fig.  345).  The  tube  is  lubricated  and  slipped  into  the  rectum, 
the  upper  metal  tube  is  connected  with  the  irrigating  vessel  and 
the  lower  connected  with  a  long  rubber  tube  leading  into  a  suitable 


PROLAPSE   OF   RECTUM,   PERINEAL  PROTECTOMY,    ETC.    555 

vessel  (Fig.  346).  In  this  way  copious  lavage  of  the  wound  may 
be  made  without  distention  of  the  rectum,  and  consequently 
trauma  to  the  wound  surface  is  obviated.     The  measure  may  be 


Fig.   346. — Cleansing  Rectum  with  Kemp  Tube.     Patient  in  Sims' 
Position.     Attendant's  fingers  constrict  outlet  tube  as  indications  arise. 

repeated  several  times  daily,  and  its  employment  requires  no 
special  skill.  It  is  especially  useful  in  instances  where  the  lower 
portion  of  the  rectum  has  been  subjected  to  operative  attack,  such 
as  the  Whitehead  operation,  partial  proctectomy  for  prolapse, 
and  removal  of  internal  piles  by  the  ligature  method. 

The  flow  into  the  rectum  will  be  quite  meager  unless  the  in- 
itial amount  be  held  by  the  finger  compressing  the  outlet  tube. 
The  illustration,  drawn  for  the  writer  by  Mr.  Nast  from  life, 
shows  how  the  fingers  may  be  made  to  control  the  amount  of  fluid 
permitted  to  remain  in  the  rectum  at  one  time.  When  the  tube 
is  pinched  the  rectum  is  filled  and  immediate  egress  occurs  when 
the  compression  is  released. 


CHAPTEK    XXIX 

OPERATIONS   ON    KIDNEY   AND   URETER 

Operations  on  the  kidney:  Nephropexy;  Nephrotomy;  Xephreetomy — 
Operations  on  the  ureter. 

OPERATIONS   ON   THE   KIDNEY 

Transperitoneal  approach  to  the  kidney  involves  the  same 
local  preparation  as  obtains  with  celiotomy,  and  does  not  call  for 
repetition  here  (page  422).  Lumbar  approach  is  the  method 
most  generally  employed.  The  skin  is  prepared  in  the  usual  way, 
and  the  general  preparation  is  in  all  respects  similar  to  that  em- 
ployed in  major  operations.  Cleansing  of  the  colon  should  be 
thoroughly  made  with  the  view  of  obviating  the  annoyance  of 
having  a  distended  colon  persistently  encroaching  upon  the  opera- 
tive field  during  the  manipulations.  A  collapsed  colon  shows  its 
peculiar  anatomical  characteristics  much  more  plainly  than  does 
a  distended  one,  the  latter  being  attended  at  times  with  oblitera- 
tion of  the  longitudinal  bands. 

In  either  instance  an  attempt  should  be  made  to  cause  the 
urine  to  be  in  as  physiological  a  condition  as  possible  at  the  time 
the  operation  is  carried  out.  Por  the  purpose  urotropin,  methy- 
lene blue,  sodium  benzoate  and  similar  preparations  may  be  ad- 
ministered for  several  days  or  a  week  preceding  the  operation. 
In  cases  of  infected  kidney  some  surgeons  lavage  the  pelvis  of 
the  kidney  daily  by  means  of  an  uretral  catheter  for  several  days 
before  the  operation.  This  is  a  measure  of  doubtful  utility,  as 
the  necessary  manipulations  require  unusual  skill  and,  indeed, 
even  if  properly  performed,  the  trauma  to  the  ureter  while  the 
lavage  is  being  made  is  exceedingly  liable  to  cause  irritation.  In 
a  general  way  it  may  be  said  that  an  interval  of  three  days  should 
be  permitted  to  succeed  instrumentation  of  the  ureter,  for  any 
purpose,  before  the  kidney  is  sectioned. 

556 


OPERATIONS    OX   THE    KIDNEY 


557 


During  lumbar  approach  to  the  kidney  the  patient  is  postured 
in  a  manner  to  increase  the  distance  between  the  twelfth  rib  and 
the  crest  of  the  ilium.  For  the  purpose  the  patient  is  placed  on 
the  side  opposite  to  the  one  attacked,  and  a  pad  or  cushion  placed 


Fig.   347. 


-Patient    Postured    for   Approach  to   the    Kidney  by  the   Lumbar 
Route,      (von  Bergmann.) 


under  the  dependent  loin.  Fig.  347  shows  the  patient  postured 
in  the  manner  stated.  The  operating  table  shown  in  Fig.  87  has 
an  appliance  which  allows  of  attainment  of  this  position  with  a 
device  which  permits  of  modification  of  degree  of  elevation  to 
suit  the  indications 
in  a  given  case. 
When  no  such  ap- 
paratus is  available 
an  air  cushion  (Fig. 
348), may  be  advan- 
tageously employed, 
or  a  blanket  rolled 

on  itself  to  the  desired  thickness  will  answer  the  purpose.  Xarcosis 
is  not  readily  administered  with  the  patient  in  this  position,  and 
care  must  be  exercised  in  this  connection,  so  that  respiration  be 
not  unnecessarily  interfered  with. 


Fig. 


348. — EdeboM's    Am    Cushion    for    Posturing 
Patient  for  Approach   to   Kidney. 


NEPHROPEXY 

Nephropexy  is  frequently  called  for  on  both  sides.  In  these 
cases  the  patient  is  postured  in  the  attitude  shown  in  Fig.  349. 
The  administration  of  the  narcotic  becomes  still  more  difficult 
under  these  circumstances,  and  respiration  must  be  carefully  ob- 
served with  the  view  of  altering  the  position  of  the  patient 
at  intervals,  if  the  necessity  arises. 


55S 


OPERATIONS   ON   THE   KIDNEY  559 

Following  nephropexy  the  patient  is  placed  in  a  bed  with  its 
lower  portion  elevated  six  inches.  This  is  intended  to  relieve 
strain  upon  the  retaining  sutures.  In  some  instances  the  wound 
about  the  kidney  is  packed  with  the  view  of  causing  adherence  of 
the  kidney  by  cicatricial  contraction.  In  either  event  the  position 
stated  should  be  maintained  for  a  week  following  the  operation, 
unless  some  indication  to  the  contrary  present.  When  primary 
union  is  aimed  at,  the  dressing  is  not  disturbed  until  the  eighth  to 
tenth  day  following  the  operation. 

If  gauze  packing  has  been  employed,  the  pack  is  removed  on 
the  third  day  following  the  operation  and  fresh  gauze  introduced. 
This  manipulation  is  repeated  at  intervals  of  forty-eight  hours 
until  complete  healing  takes  place. 

A  small  quantity  of  blood  is  at  times  present  in  the  urine  fol- 
lowing nephropexy,  especially  if  the  kidney  capsule  has  been  sec- 
tioned and  its  flaps  employed  in  the  fixation.  Hematuria  follows 
in  instances  in  which  the  kidney  capsule  has  not  been  invaded, 
this  no  doubt  being  due  to  the  trauma  of  the  kidney  tissue  which 
results  in  sufficient  contusion  to  cause  the  bleeding.  The  symp- 
tom is  of  no  great  import,  except  in  instances  in  which  the  bleed- 
ing is  sufficient  to  form  a  clot  and  the  passage  of  clots  through  the 
ureter  is  accompanied  by  symptoms  quite  typical  of  renal  colic. 
As  a  rule  the  administration  of  an  opiate  will  control  the  pain. 
When  kidney  colic  follows  nephropexy  diuretics  had  best  not  be 
given  in  large  quantity.  The  pressure  from  the  urine  behind  the 
clot  causes  much  pain,  and  it  is  best  to  permit  the  clots  to  pass 
into  the  bladder  under  slight  pressure.  When  the  clots  reach  the 
bladder  there  may  be  some  tenesmus  and  sudden  arrest  of  urinary 
discharge  from  the  urethra,  the  outcome  of  mechanical  obstruction. 
This  is  usually  not  severe,  and  the  bladder  symptoms  promptly 
disappear  when  the  clots  are  passed.  Clots  from  the  kidney  are 
usually  long  and  narrow,  and  are  not  of  sufficient  size  to  necessi- 
tate removal  by  bladder  lavage.  However,  if  the  bladder  symp- 
toms persist,  a  copious  lavage  of  that  organ  with  warm  boric  acid 
solution  through  a  roomy  catheter  will  effect  removal  of  the  of- 
fending agents.  On  the  whole,  instrumentation  of  the  bladder  for 
removal  of  clots  from  the  kidney  should  be  avoided  if  feasible, 
as  infection  finds  an  exceedingly  favorable  condition  of  affairs 
for  development  under  the  circumstances. 


560  OPERATIONS    ON   KIDNEY   AND    URETER 

Patients  should  be  confined  to  bed  for  two  weeks  following 
nephropexy,  at  the  end  of  which  time  a  proper  abdominal  sup- 
porter (Fig.  300)  or  corset  (Fig.  302)  should  be  worn  for  sev- 
eral months.  More  especially  is  the  wearing  of  supporting  ap- 
pliances indicated,  as  floating  kidney  is  usually  a  part  of  a  more 
or  less  general  enteroptosis. 

NEPHROTOMY 

Nephrotomy  is  invariably  followed  by  drainage.  When  ab- 
scess is  present,  tube  drainage  is  commonly  employed,  and  the 
perinephritic  area  drained  with  gauze.  When  the  operation  con- 
templates only  removal  of  a  calculus  without  coexisting  infec- 
tion, gauze  drainage  alone  will  suffice  the  indications.  In  the 
former  event  (of  abscess),  the  tube  drain  is  left  in  situ  until  the 
superficial  wound  is  freely  granulating,  and  the  latter  is  cleansed 
and  repacked  every  alternate  day  until  these  conditions  obtain. 
In  this  way  an  avenue  of  exit  for  the  discharge  of  infective  secre- 
tions together  with  the  urine  which  does  not  find  its  way  at  once 
into  the  normal  passages  is  furnished,  and  the  occurrence  of  the 
infiltration  of  the  postperitoneal  tissue  is  obviated.  If  the  drain- 
age is  interfered  with,  the  secretions  accumulate  in  the  perirenal 
tissue,  infiltrate  the  subserous  fat  and  the  connective  tissue  in 
the  region  of  the  kidney,  at  times  invading  the  pelvis  and  point- 
ing anteriorly  over  the  pubis  in  the  space  of  Betzius.  The  tube 
drainage  should  not  be  discarded  until  the  discharge  from  the 
cavity  is  seropurulent  or  serous,  when  the  tubes  may  be  removed 
and  silk-worm  gut  or  horsehair  drainage  (Figs.  147  and  149), 
substituted,  until  final  repair  takes  place.  If  for  any  reason  re- 
tention of  inflammatory  exudates  occur  during  the  after-treatment, 
the  condition  is  met  along  the  lines  usually  employed  with  abscess, 
i.e.,  incision  and  drainage. 

Renal  colic  with  its  characteristic  symptoms  follows  nephrot- 
omy, in  some  cases  as  the  result  of  the  passage  of  blood  clots  or 
inflammatory  exudate  through  the  ureter.  Its  occurrence  has  been 
taken  up  under  the  head  of  nephropexy  (page  559).  Patients 
afflicted  in  this  way  are  apt  to  be  discouraged  when  this  occurs, 
on  the  ground  that  they  believe  the  object  of  the  operation  has  not 
been  achieved,  indeed  the  practitioner  may  conceive  the  same 
notion.     The  discovery  of  blood  clots  in  the  urine  will  soon  dis- 


OPERATIONS   ON  THE   KIDNEY  561 

sipate  this  idea.  Colic  is  most  likely  to  follow  nephrotomy  when 
the  kidney  has  been  made  the  subject  of  attack  close  to  or  at  the 
renal  pelvis. 

Urinary  fistula  logically  is  more  commonly  a  sequel  to  ne- 
phrotomy than  obtains  with  nephrectomy,  although  in  rare  in- 
stances urinary  fistula  has  occurred  sequentially  to  nephrectomy 
when  the  ureter  has  been  removed  low  down,  the  urine  from  the 
opposite  kidney  damming  up  in  the  bladder  and  forcing  its  way 
through  the  stump  of  the  ureter  and  into  the  nephrectomy  wound, 
forming  an  infiltrate  which  after  discharge  leaves  a  fistulous  tract 
opening  on  the  skin  which  intermittently  discharges  urine.  The 
discharge  of  urine  from  the  lumbar  wound  after  nephrotomy  does 
not  necessarily  mean  that  the  ureter  is  obstructed.  It  may  be  the 
result  of  the  discharge  of  urine  into  the  cavity  which  has  been 
drained  externally  from  the  walls,  which  are  made  up  of  func- 
tionating kidney  parechyma.  Under  these  circumstances  the 
urine  naturally  goes  in  the  direction  of  least  resistance,  and 
this  is  toward  the  skin.  When  repair  of  the  cavity  takes  place, 
the  urine,  in  the  majority  of  instances,  takes  its  normal  route  of 
exit  through  the  ureter,  as  the  drainage  opening  grows  smaller 
and  ultimately  the  fistula  heals.  When  the  fistula  is  established, 
the  wound  should  be  dressed  once  or  possibly  twice  daily  accord- 
ing to  the  amount  of  urine  discharged  through  the  external  open- 
ing, and  the  skin  surrounding  the  wound  must  be  kept  clean. 
The  contiguous  skin  should  be  coated  with  an  ointment  consist- 
ing of  sterile  vaseline  and  aristol.  This  acts  largely  mechanically 
and  prevents  irritation. 

When  the  discharge  of  urine  from  the  fistula  becomes  slight, 
and,  judging  from  the  total  quantity  of  urine  passed  by  the  nor- 
mal route,  it  is  a  fair  inference  that  the  ureter  on  the  sectioned 
side  is  patent,  tincture  of  iodin  may  be  injected  into  the  fistulous 
tract,  with  the  view  of  stimulating  repair  by  a  reactionary  in- 
flammatory proliferation  of  connective  tissue.  If  there  be  any 
doubt  as  to  the  reestablishment  of  the  flow  of  urine  into  the  blad- 
der on  that  side,  cystoscopy,  after  methylene  blue  has  been  given, 
may  aid  in  determining  whether  urine  comes  from  the  afflicted 
side. 

If  a  permanent  or  persistent  fistula  is  established  and  the  dis- 
charge of  urine  from  the  tract  is  sufficient  in  quantity,  a  urinal 


562 


OPERATIONS    ON   KIDNEY  AND   URETER 


may  be  worn  which  permits  the  patient  to  go  about  with  little  in- 
convenience  (Fig.   350).     The  question  of  operative  attempt  to 
reestablish  the  normal  course  of  the  urine  or  the  question  of  ne- 
phrectomy are  not  prop- 


> 


\ 


erly  discussed  here.  In 
a  general  way,  it  may  be 
said  that  the  wearing  of 
an  apparatus,  as  indi- 
cated, will  permit  the 
patient  to  go  about  and 
regain  his  general 
health,  fitting  him  bet- 
ter for  subsequent  surgi- 
cal manipulations. 

NEPHRECTOMY 

^Nephrectomy  is  fol- 
lowed by  much  the  same 
local  treatment  em- 
ployed after  nephrot- 
omy. In  the  absence  of 
infection,  the  wound  is 
quite  closed  by  suture 
and  drainage  from  its  dependent  portion  is  made.  For  the  purpose 
the  material  discussed  above  (page  189)  is  employed.  The  selec- 
tion between  tube,  textile  fabric,  or  capillary  drainage  depends 
upon  the  character  and  magnitude  of  the  affliction  for  which 
nephrectomy  is  made.  When  suppuration  is  present  tube  drainage 
should  be  employed  for  at  least  five  days  after  the  enucleation. 
Textile  fabric  drainage  may  then  be  substituted,  and  when  there 
has  been  much  oozing  and  considerable  trauma  to  the  contiguous 
soft  parts,  the  cigarette  drain  (Fig.  154)  may  be  used.  Drainage 
with  strands  of  silk-worm  gut  or  horsehair  may  be  employed  when 
the  discharges  become  moderate  in  quantity. 

Uremia  is  a  menace  of  some  import  following  nephrectomy. 
It  may  follow  nephrotomy,  but  is  less  likely  to  occur  after  the 
latter  operation  than  with  the  former,  for  obvious  reasons.  The 
quantity  of  urine  excreted  after  nephrectomy  should  be  carefully 
recorded,  and  a  quantitative  analysis  of  the  proportion  of  solids 


y*c& 


Fig.  350.  —  Urinal  Worn  by  Patient  with 
-Urinary  Fistula.  This  apparatus  will  be 
found  serviceable  irrespective  of  location  of 
fistula. 


OPERATIONS   ON   THE   KIDNEY  563 

should  be  made.  In  all  cases  free  catharsis  should  be  employed 
as  soon  as  the  postoperative  vomiting  is  controlled,  with  the  view 
of  eliminating  a  portion  of  the  end  products  of  metabolism  by 
the  bowel.  As  soon  as  it  becomes  manifest  that  the  remaining; 
kidney  is  not  capable  of  eliminating  the  necessary  amount  of  urea, 
the  skin  should  be  used  for  the  purpose  by  encouraging  perspira- 
tion. The  patient  is  caused  to  perspire  by  the  administration  of 
pilocarpine  gr.  one-sixth  hypodermatically  every  four  hours,  and 
the  methods  of  provoking  perspiration  by  heat  should  be  em- 
ployed. Dry  heat  is  preferable  to  moist  heat,  the  former  being 
better  borne  by  the  patient.  Vomiting  should  not  be  discouraged 
after  it  becomes  manifest  that  the  stomach  is  eliminating  urea, 
and  the  catharsis  may  be  produced  by  colic  lavage. 

In  most  instances  the  kidney  excretion  is  lessened  after  a 
major  operation  of  any  kind,  partly  as  the  outcome  of  shock  and 
in  part  because  of  the  narcosis.  Undue  meddlesomeness  should 
not  be  indulged  in.  Persistent  vomiting  should  arouse  suspicion 
with  respect  to  uremia.  Diruetics  should  not  be  indiscriminately 
employed.  The  remaining  kidney  is  already  overburdened  with 
work,  and  an  additional  tax  upon  it  should  be  avoided.  The  gen- 
eral principle  of  meeting  the  indication  is  to  use  the  various  chan- 
nels of  elimination  until  such  time  as  a  physiological  balance  is 
established.  In  most  instances  this  is  soon  attained,  and  the  prog- 
nosis, with  due  care  in  the  way  stated,  is  not  particularly  unfa- 
vorable. For  some  considerable  time  the  diet  of  the  patient  should 
contemplate  avoidance  of  large  quantities  of  nitrogenized  food, 
with  the  view  of  lessening  the  labor  of  the  remaining  kidney. 
Urinary  fistula  following  nephrectomy  is  taken  up  above  (page 
561). 

Peritonitis  follows  extra-peritoneal  nephrectomy  in  some  in- 
stances ;  its  consequences,  such  as  intestinal  obstruction,  mechan- 
ical and  otherwise,  is  already  taken  up ;  its  treatment  is  in  no 
respect  different  than  when  it  is  a  complication  subsequent  to 
celiotomy  (page  451).  Permanent  removal  of  drainage  agents, 
removal  of  sutures,  and  the  indications  for  change  of  dressing  are 
similar  to  those  already  taken  up  under  the  general  considerations 
of  these  questions. 


564  OPERATIONS    OX    KIDNEY   AND    URETER 

OPERATIONS   ON   THE   URETER 

"When  the  ureter  is  attacked  by  the  transperitoneal  route,  the 
preparation  of  the  patient  and  the  after-treatment  as  regards  the 
part  the  peritoneal  sac  always  plays  in  these  problems,  are  the 
same  as  obtaiii  with  celiotomy,  and  are  described  under  that  head 
(page  422). 

The  extra-peritoneal  method  of  approach  is  the  one  most  com- 
monly employed  in  this  class  of  cases. 

The  position  of  the  patient  is  that  of  the  lateral  semi-prone 
posture,  the  abdomen  being  slightly  turned  toward  the  table.  The 
cushion  or  similar  device  employed  during  the  approach  to  the 
kidney  is  not  of  service  in  this  connection,  as  it  prevents  the  in- 
testine from  dropping  forward  and  away  from  the  operative  field. 
Operations  involving  invasion  of  the  ureter  are  invariably  fol- 
lowed by  drainage.  The  same  general  rules  with  respect  to  the 
change  of  dressings,  the  kind  of  drainage  material  best  suited  for 
the  purpose,  etc.,  apply  in  this  situation  as  are  applicable  to  the 
kidney  (page  560). 

Urinary  fistula  is  also  taken  care  of  in  the  manner  stated  in 
connection  with  operations  on  the  kidney.  When  infection  al- 
ready exists  at  the  time  of  the  operation,  tube  drainage  is  em- 
ployed until  the  character  of  the  discharged  secretions  becomes 
serous  or  seropurulent.  When  the  ureter  is  implanted  into  the 
skin,  the  wound  must  be  cleansed  twice  daily  and  the  measures 
related  above  assiduously  carried  out. 

Interference  with  drainage  and  free  discharge  of  urine  will 
stand  in  a  causative  relationship  to  inflammatory  infiltration, 
extravasation  of  urine  and  formation  of  abscess,  septicemia  and 
the  like  as  obtains  from  this  cause  in  connection  with  operations 
on  the  kidney.  This  may,  however,  be  said  as  regards  ureteral 
obstruction,  that  if  the  kidney  is  functionating,  arrest  of  the  free 
discharge  of  urine  is  followed  more  certainly  by  the  complica- 
tions mentioned  than  attends  with  attack  upon  the  kidney  in  in- 
stances where  the  ureter  is  patent.  This  should  be  borne  in  mind, 
and  the  patency  of  the  avenue  of  drainage  must  be  carefully  con- 
served. 

Grafting  of  the  ureter  into  the  bladder  should  be  followed  by 
drainage  of  the  bladder  itself.     Distention  of  the  urinary  blad- 


OPERATIONS    ON   THE   URETER  565 

der  following  plastic  anastomosis  subjects  the  line  of  suture  to 
strain,  and  may  result  in  separation  of  the  parts.  For  the  pur- 
pose the  bladder  is  drained  with  a  retention  catheter  (Fig.  354). 
If  lavage  of  the  bladder  is  regarded  as  indicated  during  the  first 
five  or  six  days  following  the  operation,  the  measure  must  be 
carefuly  carried  out,  no  more  than  three  ounces  of  cleansing  fluid 
being  introduced  at  a  time,  and  the  bladder  be  allowed  to  empty, 
itself  before  additional  fluid  is  injected.  Distention  of  the  blad- 
der is  best  avoided  by  the  return  flow  attachment  described  above 
(page  538).  However,  it  must  be  remembered  that  the  outward 
flow  is  not  as  rapid  as  that  of  entrance,  and  the  same  precaution 
with  regard  to  the  quantity  introduced  at  a  time  must  be  ob- 
served, as  attends  the  manipulation  when  only  a  single  tube  is 
employed  for  the  purpose.  In  cases  of  this  sort  the  wound  of 
approach  is  also  drained  in  the  manner  stated  above,  with  the 
view  of  taking  care  of  any  leakage  which  may  occur.  This  fact 
should,  however,  not  engender  disregard  of  the  precautions  dis- 
cussed in  connection  with  bladder  drainage. 


CHAPTEE    XXX 

OPERATIONS  ON  THE   BLADDER  AND   PROSTATE 

GLAND 

Operations  on  the  bladder:  Suprapubic  cystotomy;  Temporary  suprapubic 
drainage;  Permanent  suprapubic  drainage  following  cystotomy — Perineal 
prostatectomy. 

OPERATIONS   ON   THE   BLADDER 

SUPRAPUBIC    CYSTOTOMY 

Suprapubic  invasion  of  the  bladder  does  not  mean  opening  of 
the  peritoneal  sac  in  the  majority  of  instances.  However,  the  re- 
lationship the  peritoneum  bears  to  the  space  of  Retzius  is  not  by 
any  means  typical,  and  accidental  invasion  of  this  membrane 
may  occur.  Again,  a  certain  number  of  operations  made  upon 
the  bladder  contemplate  peritoneal  invasion.  For  these  reasons 
operations  of  this  sort  should  be  preceded  by  the  same  prepara- 
tion, both  general  and  local,  employed  for  celiotomy,  and  the 
Trendelenburg  posture  during  the  operation  should  be  provided 
for. 

In  addition  to  this,  the  bladder  should  be  lavaged  for  several 
days  before  the  operation  with  the  view  of  cleansing  the  mucosa. 
In  many  instances  the  mucosa  is  already  infected  at  the  time  of 
the  operative  attack,  and  this  should  be  treated  as  such  for  a 
period  of  time  as  seems  permissible  in  view  of  the  conditions 
present  calling  for  operative  relief.  For  the  purpose  a  solution 
of  potassium  permanganate,  1  in  1,000,  may  be  employed.  Uro- 
tropin  in  doses  of  ten  grains  three  times  daily  may  be  given  for 
several  days  before  the  oiieration,  with  the  view  of  contributing 
to  the  desired  end. 

Immediately  before  the  operation  the  bladder  is  distended 
with  ten  or  twelve  ounces  of  sterile  saline  solution,  in  order  to  in- 

566 


OPERATIONS  ON  THE  BLADDER  567 

crease  the  extra-peritoneal  area  of  the  bladder  above  the  pubic 
bones.  If  infection  be  markedly  present  at  the  time  of  the  opera- 
tion, the  bladder  may  be  thoroughly  lavaged  with  the  potassium 
permanganate  solution  just  previous  to  section,  and  this  replaced 
with  saline  solution  before  the  operation  is  begun. 

TEMPORARY    SUPRAPUBIC    DRAINAGE 

Temporary  suprapubic  drainage  of  the  bladder  is  established 
following  opening  of  the  bladder  in  this  situation.  This  is  true 
whether  the  section  has  been  made  for  the  removal  of  stone,  tu- 
mors, or  for  prostatectomy.  For  the  purpose  the  bladder  wall  is 
inverted  around  a  rubber  catheter,  which  in  turn  is  connected 
with  an  appropriate  vessel  by  means  of  a  long  tube.  As  the  angle 
at  which  the  drainage  tube  enters  the  bladder  is  that  of  about 
90  degrees  to  the  body,  the  tube  is  likely  to  kink  and  become  ob- 
literated. In  addition  to  this,  the  elasticity  of  the  bent  tube 
makes  tension  on  the  sutures,  objections  which  should  be  over- 
come. For  the  purpose  it  is  best  to  use  an  angular  catheter  (Fig. 
351  j.     The  intravesical  portion  may  be  made  shorter  as  the  con- 


Fig.  351. — Angular  "Double  Flow"  Soft  Catheter  for  Suprapubic  Drainage 

of  Bladder. 


ditions  present,  so  that  when  introduced  the  angle  of  the  device 
is  a  little  above  the  level  of  the  skin.  The  bladder  may  be  lavaged 
through  one  tube,  and  the  fluid  flows  out  through  the  other, 
though  care  must  be  exercised  not  to  inject  a  sufficient  quantity 
of  fluid  to  bring  strain  upon  the  sutures. 

To  obviate  the  latter  contingency  and,  indeed,  to  remove 
the  objections  mentioned  in  all  respects,  suprapubic  drainage 
of  the  bladder  may  be  made  by  means  of  the  device  shown  in 


568    OPERATIONS    ON   THE   BLADDER   AND    PROSTATE    GLAND 

Fig.  352.   The  largest  tube  drains  the  bladder,  and  the  angular  at- 
tachment, the  glass  tube,  is  connected  with  a  longer  one  draining  in- 


Fig.  352. — Marion  Soft  Rubber  Apparatus  for  Drainage  and  Cleansing 
of  the  Bladder  Following  Suprapubic  Prostatectomy. 


to  a  vessel  (Fig.  353).   Cleansing  solutions  may  be  introduced  into 
the  bladder  through  the  small  catheter,  which  is  furnished  with  a 


Fig.  353. — Apparatus  for  Drainage  and  Cleansing  of  Bladder  (shown  in  Fig. 
352)  in  situ.  The  cleansing  fluid  is  injected  into  the  smaller  tube  and  finds  ready 
egress  through  the  larger  one. 


OPERATIONS    ON   THE    BLADDER 


569 


wide  mouth  to  permit  of  easy  access  of  the  nozzle  of  a  syringe. 
The  large  drainage  tube  permits  of  exit  of  the  cleansing  fluid  so 
readily  that  deleterious  distention  of  the  bladder  becomes  quite 
inrpossible.  Between  the  intervals  of  treatment  the  smaller  cath- 
eter is  clamped.  The  question  of  drainage  of  the  bladder  through 
the  urethra  as  supplementary  to  suprapubic  drainage  may  be 
taken  up  here.  It  may  be  said  that,  as  a  rule,  suprapubic  drain- 
age meets  the  indications.  However,  in  some  instances,  espe- 
cially where  the  bladder  is  severely  infected,  there  is  no  objection 
to  the  additional  use  of  dependent  drainage.  For  this  purpose  the 
retention  catheter  shown  in  Figs.  354,  355  and  356  may  be  used 
Fig.  354  shows  the  mushroom  retention  catheter.     The  enlarge- 


Fig.  354. — Mushroom  Retention  Catheter  for  Drainage  of  the  Bladder  per 

urethram. 

ment  near  the  tip  is  engaged  beyond  the  neck  of  the  bladder  and 
effectually  prevents  its  expulsion.  When  the  catheter  is  intro- 
duced, the  mushroom  enlargement  is  obliterated  by  inserting  into 
its  lumen  the  stylet  (Fig.  355),  which  is  curved  to  conform  to 


Fig.    355. 


-Specially    Constructed    Stylet    for    Introduction    of    Mushroom 
Catheter. 


the  shape  of  the  ordinary  steel  sound.      The  distal  end  of  the 
catheter  is  held  by  the  loop  of  the  handle  of  the  stylet  and  the 


570    OPERATIONS    ON   THE   BLADDER   AND    PROSTATE   OLAND 

degree  of  tension  employed  is  sufficient  to  obliterate  the  mush- 
room (Fig.  356)  to  a  sufficient  extent  to  make  insertion  of  the 
catheter  into  the  bladder  an  easy  matter.  When  the  stylet  is  with- 
drawn, the  catheter' reassumes  its  original  form. 

In  these  instances  lavage  is  accomplished  by  washing  through 
and  through  in  either  direction,  though  on  general  principles  the 
injection  should  be  made  suprapubically  and  the  urethral  drain 
be  made  to  evacuate  the  contents  of  the  bladder. 


Fig.    356. — Mushroom    Catheter    Drawn    Over    Stylet    Obliterating    Distal 
Widening  to  Facilitate  Introduction  Into  Bladder. 

Following  the  removal  of  neoplasms,  foreign  bodies  or  stone, 
drainage  need  not  be  employed  for  more  than  six  days.  At  the 
end  of  this  time  the  tube  is  removed  and  the  bladder  catheterized, 
at  first  every  six  hours  and  later  every  eight  hours.  Before  each 
catheterization  the  patient  is  instructed  to  attempt  to  void  spon- 
taneously the  urine,  and  failing  in  this  the  catheter  is  used.  In 
all  instances,  even  though  spontaneous  discharge  of  urine  occur, 
the  bladder  should  be  catheterized  and  lavaged  once  daily  until 
all  evidence  of  inflammatory  exudate  disappears.  Prolonged 
drainage  of  the  bladder  results  in  lack  of  control  of  the  function 
of  urination,  and  this  should  be  obviated  in  the  manner  stated. 
The  valvular  arrangement  of  the  bladder  wall  surrounding  the 
catheter  is  regarded  as  preventing  leakage  when  the  suprapubic 
drain  is  removed.  Unfortunately  this  does  not  obtain  in  all  in- 
stances. While  leakage  does  not  always  occur  when  the  patient 
is  quiescent,  efforts  at  urination  are  usually  attended  with  the 
discharge  of  a  certain  amount  of  urine  through  the  suprapubic 
wound.  When  the  patient  attempts  to  pass  the  urine  by  way  of 
the  urethra,  the  wound  should  be  exposed  and  the  patient  pos- 
tured on  the  bed  pan  or  similar  device.  The  urine  which  leaks 
from  the  wound  is  thus  discharged  into  a  proper  receptacle,  rather 
than  allowed  to  saturate  the  dressing.  The  wound  is  cleansed 
and  redressed  subsequent  to  each  urination  until  leakage  no 
longer  occurs.  In  this  way  infiltration  of  the  tissues  contiguous 
to  the  wound  is  avoided  and  secondary  infection  is  also  obviated. 


OPERATIONS    ON   THE    BLADDER 


571 


The  superficial  suprapubic  wound  is  usually  approximated 
with  silk-worm  gut  sutures,  and  these  are  left  in  situ  for  ten  days, 
unless  infection  of  the  cellular  tissue  beneath  require  their  earlier 
removal.  If  this  occurs,  the  lower  sutures  may  be  removed,  drain- 
age established,  and  the  wound  lightly  packed  with  gauze.  The 
upper  sutures,  i.e.,  those  above  the  point  of  exit  of  the  bladder 
drain,  do  not  usually  require  removal,  and  their  maintenance  in 
place  contributes  much  to  the  ultimate  comj)lete  repair. 

Following  suprapubic  prostatectomy  the  drainage  is  left  in 
place  as  long  as  there  is  any  foul  urine.  In  some  instances  this 
requires  weeks  of  time.  The  cleansing  of  the  site  of  removal  of 
the  gland  is  quite  essential,  and  should  be  made  several  times  daily. 
Small  areas  of  tissue  frequently  undergo  sloughing  at  the  site  of 
the  deep  wound,  and  their  removal  is  much  facilitated  by  the  em- 
ployment of  the  apparatus  shown  in  Fig.  352.  Patients  who  have 
been  subjected  to  suprapubic  removal  of  the  prostate  gland  are  not 
kept  in  bed  longer  than 
the  time  required  for  re- 
covery from  the  narcosis, 
but  are  placed  in  the  sit- 
ting position  at  this  time. 
The  care  of  the  intra- 
vesical    portion     of     the      g 

drainage     apparatus      is      \\ 

taken    up    more    largely      -v5— -• 

under  perineal  prosta- 
tectomy (page  573). 

PERMANENT  SUPRAPUBIC 
DRAINAGE  FOLLOWING 
CYSTOTOMY 

This    measure    is    em-  I  j 

ployed  in  instances 
where  there  is  an  im- 
permeable obstruction  to 
the  egress  of  urine  or  in  ''■"''■•■•l-;-.i.-:ij 

cases      of      uncontrollable     Fig.   357. — Permanent    Suprapubic    Drainage 

CVStitis  after  drainage  for  Jure       A,    Plate   fitting    against    abdomen; 

J  °  B,  Plate  to  go  inside  belt;  C,  Rubber  tube  into 

Several      days      has      been  bladder;   D,  Rubber  tube  to  urinal.      (Keyes.) 


572   OPERATIONS   ON   THE   BLADDER   AND   PROSTATE   GLAND 


made,  as  described  under 
temporary  bladder  drainage. 
The  apparatus  found  most 
useful  in  these  cases  is 
shown  in  Figs.  357  and  358. 
Fig.  357  shows  a  lateral 
view  of  the  appliance. 


It  is  made  of  silver  and 
hard  rubber.  The  tube  must 
be  of  sufficient  caliber  to 
carry  off  thick  mucus  and 
clots.  A  short  rubber  drain- 
age tube  is  slipped  over  the 
exteremity  A,  and  this  is  in- 
troduced through  the  fistula 
into  the  bladder.  The  tube  is 
held  in  place  by  a  home-made 
washable  belt  passing  outside 
the  smaller  disk  (not  between 
the  two),  and  tight  enough  to 
press  the  inner  disk  firmly 
against  the  skin,  so  that  no  urine  can  es- 
cape outside  of  the  tube.  Continuous 
drainage  may  be  maintained  by  attaching 
the  outer  side  of  the  tube  to  a  leg  urinal 
(Fig.  359).  If  the  bladder  will  toler- 
ate a  little  fluid,  it  is  more  convenient 
to  cork  the  tube  and  allow  "  hypogas- 
tric urination "  at  stated  intervals. 
(Keyes.) 


Fig.  358. — Front  View  of  Apparatus  for 
Permanent  Sltprapubic  Drainage  of 
Bladder.    '(Keyes.) 


through 


If  the  measure  is  used  for  cystitis 
and  through,  lavage  can  be 
practiced  by  the  introduction  of  a 
catheter  through  the  uretha.  Lavage 
may  be  made  through  the  suprapubic 
opening.  The  rubber  tube  within  the 
bladder  must  be  changed  every  twenty-    Fig.  359. — Leg  Urinal  Used  in 

xi  it  1     ,  •  Conjunction  with  Perma- 

tour    hours    and    a    clean    one    substi-         _  T     a  t. 

nent    Suprapubic    Drain- 

tuted.      The  fistula  itself,  together  with  age  Apparatus.     {Kexjes.) 


PERINEAL   PROSTATECTOMY  573 

the  surrounding  skin,  should  be  cleansed  daily,  at  the  time  the 
intravesical  portion  of  the  drainage  apparatus  is  changed.  For  the 
purpose  a  mild  solution  of  potassium  permanganate  or  similar 
preparation  may  be  employed.  The  skin  surrounding  the  wound 
may  be  dusted  with  an  antiseptic  powder.  Those  devoid  of  odor 
are,  of  course,  to  be  used  for  obvious  reasons.  If  at  any  time  the 
use  of  the  apparatus  is  no  longer  necessary,  the  fistula  heals  very 
rapidly. 

PERINEAL   PROSTATECTOMY 

The  preparation  of  the  patient  for  perineal  prostatectomy 
should  contemplate  cleansing  of  the  bladder  for  several  days  be- 
fore the  operation.  Sufficient  enlargement  of  the  prostate  gland 
to  justify  its  removal  also  causes  retention  of  residual  urine,  de- 
composition of  the  urine  and  infection  of  the  bladder.  The  pro- 
tracted use  of  the  catheter,  as  has,  indeed,  usually  preceded  the 
attempt  at  operative  relief,  together  with  the  factors  mentioned, 
produce  a  condition  of  chronic  inflammation  in  the  bladder  mu- 
cosa which  makes  sterilization  of  this  membrane  practically  im- 
possible. However,  persistent  lavage,  such  as  is  described  in  con- 
nection with  the  care  of  postoperative  cystitis  (page  537),  will 
lessen  markedly  the  degree  of  infection,  and  is  a  measure  well 
worth  employment,  provided  the  condition  of  the  patient  warrant 
the  delay.  Cleansing  of  the  bladder  preliminary  to  its  invasion 
has  already  been  taken  up  (page  566).  The  measure  is  perhaps 
of  greater  necessity  in  connection  with  enucleation  of  the  pros- 
tate gland  than  obtains  in  any  other  condition.  The  administra- 
tion of  urinary  antiseptics,  such  as  urotropin,  is  usually  em- 
ployed by  the  practitioner  for  a  considerable  period  of  time 
before  the  case  is  subjected  to  operative  attack.  However,  an 
increase  of  dosage  for  several  days  before  the  operation  is  at 
times  advisable. 

Prostatic  hypertrophy  is  essentially  an  affliction  of  advanced 
life.  The  precautions  taken  up  under  general  considerations 
should  be  applied  in  this  class  of  cases.  Albuminuria,  diabetes, 
arterial  sclerosis  and  cardiac  disease  all  call  for  sj)ecial  manage- 
ment in  this  connection.  The  administration  of.  the  potassium 
iodid  for  a  week  before  the  operation,  under  the  restrictions  al- 
ready stated,  is  a  measure  of  seeming  utility. 


574    OPERATIONS    ON   THE   BLADDER   AND   PROSTATE    GLAND 


The  local  preparation  of  the  perineum  is  already  taken  up 
(page  548).  Cleansing  of  the  rectum,  too,  should  receive  special 
attention.  It  is  not  infrequently  necessary  to  introduce  the  finger 
into  the  rectum  during  the  operative  manipulations,  and  this  or- 
gan should  be  cleansed  and  the  precautions  with  respect  to  avoid- 
ing the  presence  of  liquids  in  the  rectum,  previously  stated, 
should  be  taken  (page  549).  At  times  it  is  necessary  to  section 
the  abdomen  during  the  operation.  Therefore  the  pubis  should 
be  shaved  and,  indeed,  the  abdominal  wall  cleansed  as  for  celi- 
otomy. 


Fig.  3G0. — Patient  in  Exaggerated  Lithotomy  Position.      {Bryant.) 

The  position  of  the  patient  during  the  operation  is  an  im- 
portant factor  with  respect  to  the  accessibility  of  the  parts.  It 
has  been  found  most  expedient  to  posture  the  patient  in  the  ex- 
aggerated lithotomy  position  (Fig.  360).  The  leg-holders  usu- 
ally  employed   during  operations   in  this   region   are   dispensed 


PERINEAL   PROSTATECTOMY 


575 


with,  and  the  lower  limbs  are  held  in  the  position  indicated  in 
the  illustration,  either  by  the  assistants  or.  by  means  of  a  folded 
sheet  or  similar  device  which  draws  the  knees  toward  the  thorax. 
The  pressure  of  the  limbs  against  the  chest  and  abdomen  inter- 
feres with  respiration,  and  it  is  at  intervals  necessary  to  lower 
the  thighs  to  afford  relief.  It  would  seem  expedient  not  to  fasten 
the  legs  firmly  in  the  position  mentioned,  but  to  have  them  held 
by  assistants,  so  that  the  necessary  modification  of  attitude  may 
be  promptly  attained.  It  is  to  be  borne  in  mind  that  narcosis  is, 
at  best,  not  well  borne  by  elderly  persons,  and  that  difficulties  in 
this  connection  are  likely  to  suddenly  arise. 

When  the  enucleation  is  completed,  drainage  is  provided  for  in 
all  instances.  When  the  section  has  been  made  in  the  median 
line,  the  tube  drain  is  surrounded  by  an  umbrella  or  chemise 


Fig.  361. — Chemise  Cannula.     (Bryant.) 


packing.     Fig.  361  shows  a  cannula  which  is  very  useful  for  the 

purpose,  the  openings  at  the  distal  end  being  used  to  fasten  tapes 

which  are  tied  about  the  body.     However,  an  ordinary  catheter 

arranged    in   the   way 

shown  in  Fig.  362  will 

answer     the     purpose 

very     well,     or     the 

"mushroom"  retention 

catheter     (Fig.     354) 

may    be    used.       The 

drain  is  inserted  into 

the  perineal  wound  to 

the  desired  extent,  and  the  "  chemise  "  is  packed  with  strips  of 

gauze  in  much  the  same  manner  as  is  done  in  connection  with  the 

Mikulicz  tamponade.    When  the  crescentric  approach  to  the  gland 

is  employed,  the  drain   is  brought  out  at  the  side  of  the  wound 


Fig.  3G2. — Chemise  Catheter.     (Bryant.) 


576    OPERATIONS    ON   THE    BLADDER   AND   PROSTATE    GLAND 

(Fig.  363).  In  either  instance  the  drain  is  connected  with  a  long 
rubber  tube  by  means  of  a  glass  connection  and  the  latter  is  led 
into  a  vessel. 

The  bladder  is  lavaged  twice  daily,  employing  a  solution  of 


Fig.  363. 


-Lateral  Drainage  or  Bladder  after  Crescentric 
Approach  to  Prostate  Gland. 


potassium  permanganate,  1  in  1,000,  for  the  purpose.  Carbolic 
acid  or  corrosive  sublimate  should  not  be  used  except  that,  per- 
haps, in  cases  of  severe  infection  the  former  may  be  used  at  con- 
siderable intervals,  and  only  in  moderate  strength  (1  in  250). 
The  packing  should  be  removed  at  the  end  of  forty-eight  hours 
and  is  not  renewed,  being  only  employed  with  the  view  of  con- 
trolling bleeding.  When  the  crescentric  approach  is  made,  packing 
is  usually  not  introduced.  The  drain  is  affixed  to  the  edge  of  the 
wound  by  a  catgut  stitch,  and  the  wound  closed  with  interrupted 
silk-worm  gut  sutures.  Most  surgeons  of  wide  experience  place 
the  patient  in  the  sitting  posture  as  soon  as  the  effects  of  the  nar- 
cosis have  disappeared.  This  would  seem  rational  in  view  of 
the  fact  that  drainage  is  best  conserved  in  this  way  and,  also,  that 


PERINEAL   PROSTATECTOMY  577 

elderly  persons  develop  very  readily  a  low  grade  of  pneumonia 
when  confined  to  bed.  It  must  be  borne  in  mind,  however,  that 
persons  advanced  in  life  are  likely  to  be  afflicted  with  changes  in 
the  cardiac  muscular  fiber,  and  that  the  shock  of  so  severe  a  meas- 
ure as  prostatectomy  is  liable  to  be  considerable.  The  pulse  rate, 
respiration  and  general  appearance  of  the  patient  must  be  taken 
into  account  before  the  mechanical  factors  in  the  problem  are 
given  precedence.  The  patient  had  best  be  supported  by  pillows, 
and  the  position  carefully  changed  without  any  exertion  on  part 
of  the  patient  for  two  days  following  the  operation,  and  the  ef- 
fect of  a  change  of  posture  upon  the  pulse-rate  noted  with  the 
view  of  being  guided  as  to  the  propriety  of  allowing  of  additional 
effort.  The  tube  is  left  in  situ  for  a  week,  that  is,  perineal  drain- 
age of  the  bladder  is  maintained  for  that  period  of  time,  the  tube 
being  removed  once  daily  and  a  sterile  one  inserted  in  its  place. 
Some  surgeons  remove  the  perineal  drain  at  the  end  of  forty-eight 
hours,  believing  that  all  necessary  egress  of  urine  or  inflamma- 
tory exudate  will  occur  through  the  wound,  and  that  the  retention 
of  tube  drainage  in  the  neck  of  the  bladder  for  a  protracted  period 
of  time  lengthens  the  time  before  voluntary  control  of  micturition 
obtains.  The  latter  proposition  is,  of  course,  true.  However,  on 
the  whole,  it  is  best  to  drain  the  bladder  until  the  danger  of  in- 
fection and  infiltration  of  the  tissues  of  the  perineum  is  past. 
If  the  tube  is  removed  early,  the  bladder  must  be  catheterized 
twice  daily  through  the  perineal  wound.  There  are  some  cases  in 
which  tenesmus  is  so  marked  that  retention  of  the  drain  is  im- 
practicable despite  the  administration  of  antispasmodics,  and  in 
these  instances  the  measure  just  mentioned  becomes  imperative. 

After  the  immediate  symptoms  following  the  operation  have 
disappeared  the  patient  should  be  postured  on  the  side  of  the  bed 
with  a  Kelly  pad  (Fig.  13)  under  the  buttocks  in  a  good  light 
and  the  bladder  thoroughly  lavaged,  a  clean  tube  introduced,  and  a 
fresh  dressing  applied.  This  measure  should  be  thoroughly  and 
carefully  carried  out  once  daily.  As  soon  as  the  patient  is  able 
to  be  about,  the  measure  may  be  carried  out  on  the  table  and,  in- 
deed, this  is  advisable,  giving  as  it  does  a  condition  of  affairs 
which  conserves  thoroughness.  At  the  end  of  a  week  a  full-sized 
sound  is  passed  into  the  bladder,  per  urethram,  and  the  drainage 
in  the  perineum  is  abolished.     The  perineal  wound  is  now  lightly 


578    OPERATIONS   ON  THE   BLADDER   AND   PROSTATE   GLAND 

packed  with,  gauze,  held  in  place  by  means  of  a  T-bandage.  The 
patient  is  instructed  to  make  an  effort  to  pass  the  urine  sponta- 
neously every  three  hours,  irrespective  of  whether  he  has  any  de- 
sire to  do  so  or  not.  This  may  obviate  retention  of  urine,  the 
outcome  of  distention  of  a  diseased  bladder.  The  urine,  of  course, 
escapes  by  way  of  the  perineum,  and  so  the  patient  must  mictu- 
rate while  seated  over  a  proper  receptacle.  Also,  the  urine  leak- 
ing into  the  gauze  causes  the  perineal  wound  to  be  irritated  and 
the  latter  must  be  cleansed  twice  daily. 

At  first  most  of  the  urine  is  passed  through  the  perineal 
wound,  but  gradually  a  little,  and  later  more  and  more,  of  the 
urine  passes  by  way  of  the  urethra,  and  ultimately  the  perineal 
wound  closes  and  all  the  urine  passes  the  natural  way.  During 
all  this  time  close  attention  must  be  paid  to  cleanliness,  both 
of  the  perineal  wound  and  the  bladder.  Cystitis,  the  outcome  of 
prostatic  disease,  rarely  disappears  entirely,  a  small  quantity  of 
pus  being  found  in  the  urine  after  the  most  successful  cases.  This 
does  not  mean  that  instrumentation  and  lavage  of  the  bladder  and 
urethra  should  be  carried  on  indefinitely.  On  the  contrary,  the 
less  instrumentation  of  the  parts  there  be  after  prostatectomy  the 
better.  It  may  be  said  that  small  quantities  of  pus  and  no  clini- 
cal evidence  of  cystitis  is  best  not  meddled  with. 

On  the  other  hand,  cystitis  with  frequency  of  urination  and 
tenesmus  persists  after  prostatectomy  for  a  considerable  period 
of  time  in  a  certain  number  of  cases,  and  this  condition  should  be 
treated  in  the  way  cystitis  is  treated  generally.  Urinary  anti- 
septics, such  as  urotropin,  may  be  given  for  a  long  time  following 
the  operation.  A  plan  worth  following  is  to  administer  five  grains 
of  urotropin  three  times  daily  for  a  week,  and  then  intermit  the 
medication  for  a  week,  soon  after  convalescence  is  established. 
Later  on  an  occasional  use  of  an  urinary  antiseptic  may  be  in- 
dulged in. 

The  passage  of  sounds  is  employed  every  five  days  until  the 
perineal  wound  is  closed,  after  which  a  sound  is  passed  every  two 
weeks  for  three  months.  Later  than  this  the  passage  of  a  sound 
is  not  employed,  except  for  special  reasons.  A  chemical  and 
microscopical  examination  of  the  urine  should  be  made  every 
month. 


CHAPTER   XXXI 
OPERATIONS  ON   THE  SCROTUM   AND   PENIS 

Hydrocele — Castration — Varicocele — Circumcision — Plastic    operations    on    the 
penis — Urethrotomy   for  stricture. 


HYDROCELE 

Hydrocele,  if  treated  by  the  open  method  with  suture  of  the 
edges  of  the  sac  to  the  skin  and  subsequent  packing  of  the  cavity, 
contemplates  obliteration  of  the  tunica  by  granulation  repair. 
Fig.  364  shows  the  appearance  of 
the  parts  after  operation.  The  orig- 
inal packing  is  left  in  place  for  two 
days,  when  it  is  removed,  the  cavity 
irrigated  with  a  corrosive  sublimate 
solution,  1  in  2,000,  and  the  packing 
renewed.  This  procedure  must  be 
repeated  at  intervals  of  forty-eight 
hours  until  healing  by  granulation, 
from  within  outward,  is  accom- 
plished. The  sutures,  if  they  be 
of  a  non-absorbable  material  (which 
is  preferable),  are  removed  on  the 
tenth  day  following  the  operation. 
The  patient  need  not  be  confined  to 
bed  after  the  fourth  day  following 
the  operation,  and  may  be  permitted 

to  go  about  with  the  dressing  held  in  place  by  means  of  an  ordi- 
nary suspensory  bandage  after  the  sutures  are  removed  (the  tenth 
day).  Complete  healing  does  not  usually  occur  until  three 
weeks  after  the  operation.  If  the  hydrocele  be  entirely  ex- 
cised, the  wound  is  treated  in  all  respects  similarly  to 
wounds  in  other  portions  of  the  body  where  primary  union  is 
39  579 


Fig.  364. — A  ppearance  of 
Wound  after  Incision  for 
Hydrocele  (Volkmann's 
Method).     (Bryant.) 


580  OPERATIONS   ON  THE   SCROTUM   AND   PENIS 

aimed  at.  It  is  worth  bearing  in  mind,  however,  that  the  dartos 
is  liable  to  undergo  considerable  modification  of  area,  the  result 
of  its  contractility,  and  that  undue  strain  upon  the  suture  line  for 
four  days  after  the  operation  is  to  be  prevented.  For  this  reason 
the  patient  should  be  confined  to  bed  for  four  days  after  the  opera- 
tion, as  is  advised  in  connection  with  the  open  operation,  and 
should  not  be  permitted  to  go  about  until  after  the  sutures  are  re- 
moved, which  in  this  instance  may  be  done  on  the  tenth  day  fol- 
lowing the  operation.  If  infection  occur,  the  wound  is  treated  by 
drainage  and  light  packing,  as  is  described  in  connection  with  the 
care  of  infected  wounds  generally  (page  305). 

CASTRATION 

Castration,  if  done  for  malignant  disease,  is  followed  by  com- 
plete closure  of  the  wound  of  approach  and  subsequent  local  care 
similar  to  that  of  relief  of  hydrocele  by  the  excision  method. 
Oozing  and  arterial  bleeding  at  times  follow  the  operation,  dis- 
tending the  scrotum  in  the  manner  described  under  varicocele. 
The  complication  is  met  by  reopening  of  the  wound  and  ligature 
of  the  bleeding  point  or  points.  The  time  of  removal  of  sutures 
and  the  length  of  time  of  confinement  is  similar  to  that  applied 
to  hydrocele.  The  operation  of  double  castration,  unless  per- 
formed late  in  life  (how  late  is  difficult  to  say),  is  followed  by  a 
mental  depression  which  calls  for  the  exercise  of  considerable  tact, 
and  perhaps  justifiable  deceit  with  regard  to  the  sexual  function. 

VARICOCELE 

Varicocele  presents  much  the  same  problem  with  respect  to 
after-treatment  as  obtains  in  the  conditions  just  discussed.  As  a 
rule,  the  wound  is  entirely  closed  without  drainage.  It  is,  how- 
ever, wise  to  permit  a  small  drain  to  remain  in  the  inferior  angle 
of  the  wound  for  several  days  after  the  operation,  in  order  to  give 
opportunity  for  the  discharge  of  blood,  the  outcome  of  a  recur- 
rence of  oozing,  which  is  not,  in  all  cases,  apparent  at  the  time 
of  the  operation.  Tor  the  purpose  a  few  strands  of  silk-worm 
gut  may  be  used  (Fig.  147),  which  are  removed  on  the  third  day 
following  the  operation.     When  drainage  is  omitted,   the  tunica 


VARICOCELE  581 

becomes  distended  with  blood,  which  at  times  causes  the  formation 
of  a  large  tumor,  and  an  infiltration  of  the  subcutaneous  tissue 
upon  the  abdomen  over  the  penis  and  down  the  thigh.  When  the 
bleeding  persists,  the  distention  extends  into  the  inguinal  canal, 
making  pressure  on  the  cord  and  testicle  which  gives  rise  to  con- 
siderable pain.     Fig.  365  shows  a  case  of  this  sort.     The  patient 


Fig.  365. — Infiltration  of  Tunica,   Scrotum  and  Penis  with  Blood  following 
Operation  for  Relief  of  Varicocele. 


had  an  unusually  extensive  venous  dilatation,  the  operative  pro- 
cedure involving  considerable  trauma  to  the  adjacent  tissues  in 
order  to  accomplish  the  purpose.  The  wound  was  reopened,  the 
clots  removed,  and  drainage  established.  The  case  illustrated  the 
lessened  coagulability  of  the  blood,  as  the  patient  had  just  re- 
covered from  an  attack  of  jaundice  due  to  gastroduodonitis. 
There  was  a  considerable  amount  of  oozing  for  some  days  after 
the  operation,  and  convalescence  was  exceedingly  protracted. 

Reopening  of  the  wound  and  removal  of  the  blood  should  not 
be  postponed  too  long,  as  in  some  instances  pressure,  necrosis,  and 
sloughing  of  the  testicle  have  occurred  as  the  outcome  of  delay. 

After  the  wound  has  been  reopened,  the  local  conditions  are 
exceedingly  favorable  to  the  invasion  of  infection.  Great  care 
should  be  exercised  to  obviate  this  occurrence.  The  contiguity  of 
the  wound  to  the  penis  makes  it  difficult  to  maintain  dry  asepsis, 
and  for  this  reason  a  wet  dressing  of  carbolic  acid,  1  in  200,  in 
sterile  water  should  be  applied.     However,  this  should  be  kept  in 


582 


OPERATIONS    ON   THE   SCROTUM   AND    PENIS 


contact  with  the  wound  only  during  the  day,  and  be  replaced  with 
a  sterile  dressing  during  the  night,  to  obviate  the  sloughing  and 
maceration  of  the  skin  consequent  to  the  prolonged  application  of 
carbolic  acid.  The  wound  should  be  scrutinized  daily,  and  any 
accumulation  of  secretion  carefully  and  gently  expressed  from  the 
scrotum.  The  patient  must  be  kept  confined  until  granulation  is 
well  established. 


CIRCUMCISION 

As  circumcision  is  usually  done  under  local  anesthesia,  the 
tissues  are  infiltrated  and  distended,  and  should  for  this  reason 
be  apposed  with  sutures  that  do  not  cause  tension.  Horsehair  or 
fine  silk-worm  gut  are  most  serviceable  for  the  purpose.  The 
penis  is  dressed  by  loosely  applying  very  soft  gauze,  which  is 
wound  about  the  penis  and  held  in  place  with  a  T-bandage,  the 

gauze  being  fastened  to 
the  later  by  means  of 
a  safety  pin  (Fig. 
366).  The  operation 
is  usually  followed  by 
an  edema  of  the  stump 
of  the  prepuce,  which, 
however,  need  cause  no 
alarm  and  subsides 
spontaneously  in  a  few 
days.  The  tissues, 
both  the  mucosa  and 
skin,  are  exceedingly 
thin,  and  the  sutures 
usually  cut  out  at  the 
end  of  a  week.  If, 
however,  the  sutures 
remain  at  the  end  of 
ten  days  they  should 
be  removed. 
The  gauze  should  be  renewed  after  each  urination.  At  the 
end  of  five  days  following  the  operation,  the  edema  will  have  dis- 
appeared and  the  line  of  union  may  then  be  covered  with  an  oint- 


Fig.  366. — Dressing  after  Circumcision. 


PLASTIC   OPERATIONS   ON   THE   PENIS  583 

ment  of  aristol  and  sterile  vaselin  and  the  clothing  protected  by 
wearing  an  apron  made  of  a  square  of  gauze  fastened  about  the 
waist  with  tapes,  the  gauze  draping  down  over  the  genitals. 

The  glans  will  be  found  to  be  quite  sensitive  to  contact  for 
some  days  following  the  removal  of  the  prepuce,  especially  if  it 
has  been  left  intact  until  adult  life.  This  may  be  overcome  by 
frequent  lavage  of  the  glans  with  cleansing  fluids  to  which  a 
small  portion  of  tannic  acid  is  added.  At  the  end  of  a  few  weeks 
the  mucosa  of  the  glans  takes  on  more  the  characteristics  of  skin 
and  the  sensitiveness  disappears.  The  dressings  should  at  all 
times  be  so  loose  as  not  to  compress  the  penis  during  erection. 

PLASTIC   OPERATIONS    ON   THE   PENIS 

Plastic  operations  on  the  penis  for  epispadius  and  hypospadius 
depend  largely  as  regards  favorable  outcome  upon  care  in  the 
after-treatment.  The  urine  should  be  made  as  aseptic  as  possible 
with  the  view  of  avoiding  infection  in  the  event  of  infiltration  of 
the  wound  areas.  For  this  purpose  urotropin  should  be  adminis- 
tered for  several  days  before  and  for  a  week  following  the  opera- 
tion. Bryant  regards  leaving  a  retention  catheter  in  the  urethra 
as  less  useful  with  respect  to  the  avoidance  of  infection,  and  be- 
lieves that  the  presence  of  the  instrument  is  irritating.  He  in- 
jects into  the  urethra  a  small  amount  of  sterile  oil  after  each  al- 
ternate urination,  and  has  found  the  procedure  very  satisfactory. 
Repeated  introduction  of  instruments  into  the  urethra  should  be 
avoided  if  feasible.  A  few  strands  of  silk-worm  gut  introduced 
into  the  opening  and  replaced  after  each  urination  is  good  prac- 
tice. Care  must  be  exercised  in  the  manipulation  to  avoid  infec- 
tion. The  occurrence  of  infection  in  any  of  the  suture  holes  should 
be  attended  with  immediate  withdrawal  of  the  suture. 

The  occurrence  of  erections  during  the  healing  is  productive  of 
failure  of  the  intent.  Pressure  upon  the  vesicula)  seminales  from 
distention  of  the  bladder  may  be  prevented  by  causing  the  pa- 
tient to  empty  the  bladder  every  four  hours  night  and  day.  The 
physiological  erection  due  to  a  full  bladder  is  thus  obviated  in 
most  instances.  The  application  of  cold,  sterile,  wet  dressings 
during  the  day  and  keeping  the  bladder  empty  at  night  is  service- 
able, though  the  execution  of  these  measures  is  somewhat  tedious. 


584  OPERATIONS   OX  THE  SCROTUM   AND   PENIS 

Nevertheless  the  precautions  in  this  connection  need  not  be  car- 
ried out  for  more  than  five  or  six  days,  a  minor  consideration  in 
comparison  to  the  intent.  Bromids  may  be  given  during  this 
time.  A  mixture  of  sodium  bromid,  thirty  grains,  and  a  quarter 
of  a  grain  of  codein  given  every  three  hours  seems  to  be  of  use. 
The  administration  of  this  combination  need  not  be  employed  for 
more  than  three  or  four  days.  An  intelligent  attendant  who  wakes 
up  the  patient  every  three  hours  during  the  night  and  causes  him 
to  empty  the  bladder,  and  who  redresses  the  parts  as  stated,  will 
contribute  much  to  a  favorable  ultimate  outcome.  It  seems  hardly 
necessary  to  state  that  the  attendant  had  best  be  of  the  male 
sex. 

The  sutures  should  be  retained  in  place  for  ten  days.  Non- 
absorbable sutures  are  preferable  in  this  class  of  cases,  as,  indeed, 
is  the  case  in  all  plastic  work.  For  the  purpose,  horsehair,  which 
may  be  introduced  with  very  slender  needles,  is  the  suture  mate- 
rial of  choice  in  operating  in  this  class  of  cases. 

URETHROTOMY   FOR   STRICTURE 

-Urethrotomy  for  stricture  should  be  prepared  for  in  much  the 
same  manner  as  is  done  preliminary  to  operations  on  the  bladder 
and  prostate.  Stricture  of  the  urethra  is  most  commonly  a  sequel 
to  gonorrheal  inflammation  of  the  urethral  mucosa  with  the  glan- 
dular elements  of  this  membrane,  the  habitat  of  the  diplococcus  of 
Neisser.  Tor  this  reason  it  is  well  to  precede  the  sectioning 
of  the  urethra  with  local  treatment  for  some  weeks  before  the 
operation  if  this  be  feasible.  Tor  the  purpose  the  patient  visits 
daily  the  practitioner,  who  irrigates  the  urethra  with  a  solution 
of  protargol,  1  in  200,  by  the  Janet-Chetwood  method,  thoroughly 
ballooning  up  the  urethra  at  each  sitting,  in  order  to  distend  the 
rugae  into  which  the  normal  urethra  is  thrown,  and  destroying  to 
a  certain  extent  at  least  the  gonococcus.  This  procedure  is  em- 
ployed each  alternate  day,  and  upon  the  day  between  the  urethra  is 
lavaged  with  a  solution  of  1  in  5,000  corrosive  sublimate.  The 
latter  step  is  employed  with  the  view  of  destroying  any  mixed 
infection  of  purulent  character. 

The  Janet-Chetwood  method  of  cleansing  the  urethra  is  em- 
ployed as  follows : 


URETHROTOMY   FOR   STRICTURE 


585 


The  proper  employment  of  the 
treatment  requires  a  receptacle  of  glass 
or  a  fountain  syringe,  hung  upon  a 
hook,  which  latter, suspended  over  a  pul- 
ley, may  be  raised  or  lowered  at  will, 
to  vary  the  pressure  of  the  column  of 
fluid;  a  conical  glass,  two-way  nozzle 
(Fig.  367)  ;  some  small,  soft-rubber 
catheters  (8  to  12  French)  with  care- 
fully beveled  eyes  and  the  scissors-like 
shut-off  (Fig.  368). 

T  h  e  alternating  shut-off  instru- 
ment clasps  the  rubber  tubes  attached 
to  the  nozzle,  and  by  a  scissors-like  mo- 
tion controls  the  inflow  and  the  out- 
flow alternately  (Fig.  369),  impeding 
the  outflow  as  the  fluid  enters  the  ure- 
thra, and  thus  securing  an  even  dis- 
tention of  the  canal  (Fig.  370),  arrest- 
ing the  inflow  when  the  urethra  is  full, 
thus  allowing  the  canal  to  evacuate  it- 
self entirely.  A  proper  distention  of 
the  urethra  is  secured  by  raising  the 
reservoir  4  or  o  feet.     Such  elevation  will  not  force  the  membranous 

urethra,  and  what  pressure 
there  is  may  be  moderated 
in  case  of  pain  by  partially 
closing  the  inflow  tube. 

The  advantages  of  the 
alternating  shut-off  are  ob- 
vious. Both  cleanliness 
and  effective  distention  of 
the  urethra  are  better  se- 
cured by  it  than  by  other 
means.  If  a  one-way  noz- 
zle is  used,  the  urethra 
may  be  properly  distended, 
but  in  order  to  effect  irri- 
gation this  nozzle  must  be 
constantly  withdrawn  and 

Fig.  368. — Chetwood's  Scissors  Shut  Off,  Used  .  ,  -..    . 

to    Control    Flow    of    Cleansing    Fluids       reinserted— a  dirty  expe<  1 1- 

used  in  the  Urethra.    (Keyes.)  ent.     If  a  catheter  is  in- 


Fig.  367. —  Chetwood's  Two-way 
Urethral  Nozzles.  The  vari- 
ous sizes  are  used  with  respect 
to  caliber  of  the  urethral  meatus. 
(Keyes.) 


586 


OPERATIONS   ON   THE  SCROTUM   AND   PENIS 


Fig.  369. — Chetwood's  Irrigator.  Filling 
the  tube  with  fluid  before  applying  it  to 
the  urethral  meatus.      (Keyes.) 


troduced  to  the  bulb  for  the 
anterior  irrigation  (retro-ir- 
rigation), the  urethra  is  not 
properly  distended,  and  many 
gonococci  in  the  sinuses  and 
the  urethral  folds  escape. 

About  one  quart  of  liquid 
is  needed  for  efficient  anterior 
irrigation,  the  time  required 
being  about  five  minutes. 

If  the  surgeon  prefers,  he 
may  irrigate  the  posterior 
uretha  with  this  apparatus, 
simply  raising  the  reservoir; 
but  it  is  better,  after  having 
first  thoroughl}'  irrigated  the 

anterior  urethra,  to  use  a  catheter  for  posterior  work. 

For  this  purpose  a  soft-rubber  catheter,  with  perfectly  beveled  eye, 

is  used.     The  size  of  the  catheter 

should  be  from  12  to  15  French. 

It  must  be  anointed  with  a  lubri- 
cant  that  will   dissolve   in  water. 

Vaselin  or  oil  will  not  suffice.     A 

saponaceous  lubricant  or  that  made 

with  Irish  moss  and  called  lubri- 

chondrin  is  entirely  suitable.     The 

catheter  must  be  introduced  slowly 

and  with  the  utmost  gentleness,  eye 

upward,  until  urine  flows,  showing 

that  the  bladder  has  been  reached. 

The     bladder     is     now     emptied 

through  the  catheter  and  then  the 

latter  is  withdrawn  a  full  inch,  so 

that  its  eye  may  lie  just  behind  the 

membranous  urethra.     Now  from 

the  irrigator  from  4  to  12  ounces 

of  fluid,  according  to  the  tolerance 

of  the  bladder,  are  thrown  in,  wash- 
ing backward  in  its  course  the  en- 
tire prostatic  sinus,  after  which  the  catheter  is  gently  withdrawn. 
The  patient  now  urinates  out  the  contents  of  his  bladder,  thus 

giving  himself  a  very  efficient  final  retrojection.     (Keyes.) 


Fig.  370. — Chetwood's  Irrigator.    The 
fluid  entering  the  urethra.      (Keyes.) 


URETHROTOMY  FOR  STRICTURE  587 

In  addition  to  this  the  patient  should  be  given  large  quantities 
of  water  for  several  days  before  the  operation,  with  the  view  of 
mechanically  cleansing  the  urinary  passages. 

When  an  external  urethrotomy  is  made,  the  precautions  men- 
tioned are  all  carried  out,  and  the  bladder  is  drained  as  is  de- 
scribed under  Perineal  Prostatectomy  (page  573).  Sectioning  of 
the  urethra  for  stricture  is,  in  a  large  number  of  instances,  fol- 
lowed by  a  chill  and  rise  of  temperature  which  is  transient  and 
diseappears  so  rapidly  that  it  is  difficult  to  conceive  the  systemic 
disturbance  as  being  due  to  sepsis.  There  is,  perhaps,  a  peculiar 
relationship  between  trauma  to  the  urethra  and  the  toxemia  which 
follows  it.  However,  the  fact  that  when  cases  are  prepared  in  the 
manner  stated  the  chill  and  rise  of  temperature  does  not,  as  a  rule, 
obtain  would  suggest  that  there  is  some  connection  in  this  regard. 
For  this  reason  a  careful  preparatory  treatment  along  the  lines 
mentioned  is  urged. 

When  the  operation  is  completed,  the  patient  is  placed  in  bed 
and  artificial  heat  is  applied  in  the  manner  described  under  Shock 
(page  227).  As  a  routine  thing  a  colic  lavage  of  saline  solution 
at  a  temperature  of  110°  P.  is  given  at  once,  and  this  is  repeated 
in  six  hours,  irrespective  of  the  occurrence  of  chill.  Whether  the 
presence  of  blood  clots  in  the  anterior  urethra  in  cases  of  internal 
urethrotomy,  or  in  a  bladder  after  deep  urethrotomy,  has  any- 
thing to  do  with  the  so-called  urethral  fever  or  not,  it  is,  of  course, 
difficult  to  say.  However,  this  much  is  true,  that  febrile  move- 
ment occurs  less  frequently  as  a  complication  later  on  (the  second 
day),  if  the  bladder  drainage  be  perfect  and  the  anterior  urethra 
is  lavaged  with  saline  solution  every  twelve  hours  after  the  opera- 
tion. The  question  of  whether  sectioning  of  the  urethra  liberates 
into  freshly  traumatized  tissue  a  certain  number  of  bacteria 
which  have  been  relatively  isolated  by  protective  exudates  is  also 
not  quite  clear.  However,  cleanliness  and  drainage,  as  indicated, 
seem  rational  procedures,  and  may  be  regarded  as  preventive  meas- 
ures in  this  connection.  The  drain  in  the  bladder  is  removed  on 
the  fourth  day  after  the  operation,  and  the  umbrella  packing  is 
changed  every  twenty-four  hours  until  this  time.  Following  re- 
moval of  the  bladder  drain  the  wound  is  dressed  with  gauze  held 
in  place  with  a  T-bandage  (Pig.  344).  Urination  now  takes 
place    for   the   most   part   through   the   perinea]    opening.      The 


588  OPERATIONS   ON   THE  SCROTUM   AND   PENIS 

wound  is  cleansed  after  each  time  the  bladder  is  emptied  and  fresh 
gauze  applied,  the  patient  assuming  the  sitting  posture  while 
voiding.  On  the  sixth  day  following  the  operation  the  anterior 
urethra  is  thoroughly  cleansed  by  injecting  through  it  a  solution 
of  protargol,  1  in  200,  in  the  manner  described  above,  and  a  full- 
sized  steel  sound  is  passed  into  the  bladder.  As  the  sound  is 
likely  to  emerge  through  the  perineal  opening,  the  latter  is 
closed  with  a  gauze  pad  firmly  pressed  against  the  wound,  and  the 
instrument  carefully  pushed  beyond  it.  Should  the  introduction 
of  the  sound  be  impracticable,  it  is  removed  after  dilating  the 
urethra  to  the  perineal  wound,  and  reintroduced  into  the  latter  and 
made  to  enter  the  bladder.  During  this  time  urinary  asepsis  is 
to  be  maintained,  as  not  infrequently  a  chill  and  its  attendant 
disturbances  obtain  subsequent  to  the  passage  of  the  sound.  In- 
deed, this  contingency  may  occur  at  any  time  until  the  healing 
is  complete. 

Daily  instrumentation  is  to  be  avoided.  Persistent  cleanli- 
ness is  essential.  However,  the  passage  of  a  sound  need  not  be 
executed  oftener  than  every  four  days.  This  instrumentation  is 
carried  on  until  the  wounds  are  healed,  is  then  done  every  eight 
days  for  six  or  seven  weeks,  every  two  weeks  for  three  months, 
once  a  month  for  six  months,  and  from  then  on  the  patient  should 
have  a  full-sized  sound  passed  every  two  months  for  a  year  or 
more.  A  favorable  outcome  is  absolutely  dependent  upon  keep- 
ing the  canal  properly  dilated  as  stated.  Eecurrence  of  stricture 
will  thus  be  avoided. 


CHAPTEK    XXXII 
OPERATIONS   ON   THE   EXTREMITIES 

Dupuytren's    contraction — Hallux    valgus — Flat-foot — Club-foot — Osteotomy — 
Resection  and  excision  of  joints — Amputations. 

Operations  on  the  extremities  involve  the  problem  of  locomo- 
tion as  far  as  the  lower  limbs  are  concerned,  and  the  ability  to 
perform  manual  labor  or  the  indulgence  in  voluntary  volitional 
action  necessary  to  life  and  comfort  as  concerns  the  upper  ex- 
tremities. For  these  reasons  the  occurrence  of  postoperative 
complications  following  operations  upon  these  parts  should  be 
carefully  guarded  against.  Infection  with  its  baneful  sequels, 
deformity  and  loss  of  function  and  impairment  of  the  range  of 
motion  of  joints,  the  outcome  of  ankylosis,  are  in  a  measure  con- 
trollable by  strict  adherence  to  asepsis  as  far  as  the  former  is  con- 
cerned, and  by  intelligently  employed  massage,  passive  and  active 
motion,  as  far  as. the  latter  is  concerned.  Operations  with  the 
view  of  correcting  deformity  do  not  achieve  the  object  unless  the 
subsequent  treatment  and  management  of  the  case  be  properly 
carried  out. 

DUPUYTREN'S  CONTRACTION 

Dupuytren's  contraction  after  the  fascial  contractures  have 
been  divided  will  recur,  unless  complete  repair  has  taken  place 
with  the  parts  in  the  corrected  position.  The  wound  is  dressed 
in  the  usual  manner,  and  the  fingers  held  in  position  by  either  a 
palmar  or  dorsal  splint.  As  the  pressure  due  to  the  stretching  of 
the  skin  of  the  palm,  of  itself,  is  liable  to  cause  sloughing,  it  is 
best  to  apply  the  splint  to  the  dorsal  aspect  of  the  hand  and  band- 
age the  parts  to  it.  Fig.  371  shows  a  splint  which  is  quite  useful 
for  the  purpose.  A  pad  of  gauze  is  placed  over  the  palm  and  the 
fingers  bandaged  to  separate  portions  of  the  splint.     The  wrist  is 

589 


590  OPERATIONS    ON   THE   EXTREMITIES 

also  encircled  with  gauze  and  the  splint  applied  over  this.  The 
splint  may  consist  of  shellac,  or  soft  wood,  or  sole-leather,  or 
malleable  "tin,  the  latter  having  the  advantage  of  permitting  of 
modification  of  the'  degree  of  extension  used. 


Fig.  371. — Dupuytren's  Contraction.  Splint  for  Maintaining  Complete  Exten- 
sion after  Operation.  The  splint  is  made  of  malleable  tin  and  can  be  bent 
slightly  upward  in  order  to  over-correct  the  deformity.     (Cheyne.) 

At  first  the  fingers  are  placed  in  the  position  of  over-exten- 
sion, though  this  is  not  at  all  times  well  borne  by  the  patient.  In 
the  event  of  the  over-corrected  position  being  painful,  or  if  the 
skin  of  the  palm  shows  any  signs  of  undue  pressure,  the  splint 
may  be  bent  to  accord  with  less  forcible  extension.  For  this 
reason  the  splint  is  best  made  of  material  which  will  permit  of 
these  manipulations.  The  wound  is  treated  as  are  wounds  in 
other  situations.  The  correcting  splint  is  worn  night  and  day  for 
three  or  four  weeks.  Later  a  splint  which  has  prolongations 
which  confine  only  the  affected  fingers  is  worn,  thus  allowing  of 
a  certain  use  of  the  member.  At  the  end  of  six  weeks  the  splint 
is  worn  only  at  night,  though  its  noturnal  application  should  be 
maintained  for  six  months.  When  the  splint  is  removed  during 
the  day,  the  hand  is  subjected  to  massage  and  kneading,  the  part 
being  covered  with  lanolin  or  other  lubricant  during  the  manipu- 
lations, with  the  view  of  softening  the  skin  and  stretching  the 
fascia  and  ligaments  of  the  joints.  The  superheated  air  appar- 
atus, such  as  is  used  for  the  treatment  of  rheumatic  joints,  may 
be  used  and  seems  to  be  of  service. 

The  deformity  is  liable  to  return  after  a  long  period  of  time, 
and  the  patient  must  be  instructed  to  employ  correcting  manipu- 
lations regularly  for  several  years  after  the  operation.  This  need 
not  be  made  a  hardship.  A  few  minutes  of  massage,  kneading, 
and  the  use  of  pulley  weights,  which  extend  mechanically  the  fin- 
gers, every  morning  will  be  found  to  meet  the  indications. 


HALLUX   VALGUS 


591 


HALLUX   VALGUS 

Hallux  valgus  when  subjected  to  operative  relief  is  followed 
by  immobilization  of  the  parts,  by  the  application  of  a  splint  to 
the  internal  surface  of  the  foot.  The  wound  is  covered  with  the 
protective  dressing,  a  gauze  pad  is  placed  between  the  large  and 
second  toes,  to  make  outward  pressure,  and  a  splint  is  applied,  as 


Fig.   372. — Lateral   Splint  for  Holding  Toe   after  Operation 
for  Hallux  Valgus.     (Foote.) 


shown  in  Fig.  372.     The  toe  is  held  in  contact  with  the  splint  by 
adhesive  plaster. 

If  no  special  indication  arises,  the  wound  is  not  dressed  until 
the  tenth  day  after  the  operation,  at  which  time  the  stitches  are 
removed.  If  there  has  been  much  oozing,  the  wound  is  drained, 
in  which  event  the  dressing  is  removed  on  the  third  day  and  the 
drain  removed.  The  parts  are  now  again  immobilized,  as  stated 
above,  and  the  wound  is  left  undisturbed  for  the  remaining  seven 


592 


OPERATIONS   ON  THE   EXTREMITIES 


days.  At  this  time  the  toe  is  moved  slightly  and  a  silicate  of 
soda  splint  applied  which  holds  the  parts  in  place.  At  the  end 
of  another  three  days  the  patient  is  permitted  to  go  about  with 
the  toe  held  in  the  position  mentioned,  the  shoe  being  cut  away 
for  the  purpose.  The  corrected  position  is  maintained  for  six 
weeks,  at  the  end  of  which  time  passive  motion  may  be  begun. 
After  recovery  the  patient  is  instructed  to  wear  a  shoe  which  will 
obviate  recurrence  of  the  deformity.     Fig.  373  shows  an  outline 


Fig.  373. — Hallux  Valgus.  Diagram  Showing  the  Principle  Involved  in  Mak- 
ing Shoes.  C  shows  the  deflection  of  the  great  toe  and  the  cramped  position  of 
the  others  entailed  by  this  kind  of  shoe.  It  will  be  seen  that  the  point  of  the  shoe 
lies  along  the  middle  line  of  the  foot.  B  shows  the  outline  of  the  sole  of  a  shoe  con- 
structed on  sound  anatomical  principles.  The  inner  border  of  the  flat  part  of  the 
sole  is  nearly  parallel  to  the  long  axis  of  the  foot,  the  boot  comes  to  a  point  opposite 
the  great  toe,  and  is  sloped  away  from  that  point  to  the  outer  border  in  accordance 
with  the  length  of  the  other  toes,  which  are  thus  not  cramped  at  all.  A,  a  very 
usual  form  of  so-called  anatomical  shoe,  which,  while  it  is  free  frcm  the  most  flagrant 
faults  of  the  shoe  shown  at  C,  is  not  so  good  as  B.  The  inner  border  of  the  sole  is 
not  quite  straight,  and  so  tends  to  deflect  the  great  toe  somewhat,  while  the  square- 
ness of  the  end  of  the  boot  both  leaves  a  lot  of  unnecessary  space  between  it  and  the 
toes  and  detracts  considerably  from  the  appearance  of  the  foot.     (Meyer.)  (Cheyne.) 


to  which  the  shoe  should  correspond.  The  important  factor  in 
the  construction  of  a  suitable  shoe  is  to  have  the  internal  line  of 
the  footwear  make  a  straight  line  from  the  metatarsophalangeal 
articulation  to  beyond  a  line  drawn  transversely  across  the  distal 
termination  of  the  great  toe.  Patients  find  it  convenient  to  wear 
a  pledget  of  cotton  between  the  great  and  second  toes  (Fig.  374) 
for  a  long  time  after  recovery  is  complete.     In  some  instances  a 


FLAT-FOOT 


593 


specially  constructed  shoe  with 
a  separate  compartment  for 
the  great  toe  (Fig.  375)  will 
be  found  of  use.  It  is  to  be 
borne  in  mind,  however,  that 
the  "  toe-post "  may  make 
pressure  upon  the  inner  sur- 
face of  the  toe,  giving  rise  to 
pain  and  annoyance,  and  its 
employment  may  have  to  be 
abandoned  for  this  reason. 
When  the  "  toe-post  "  is  used, 
it  may  be  difficult  to  insert  the 
phalanx  into  the  compartment. 
For  the  purpose  a  gauze  plug 
is  inserted  between  the  toes 
(Fig.  374),  to  which  a  string- 
is  attached.  When  the  toe  is 
felt  to  engage  in  the  compart- 
ment, the  plug  is  withdrawn 
by  means  of  the  string.  Of 
course,  the  use  of  the  device 
necessitates  the  use, of  a  digital 
sock. 


Fig.  375. — Diagram  to  Illustrate 
"Toe-post."  The  "toe-post" 
is  seen  in  the  cleft  between  the 
great  toe  and  the  second.  It  is 
made  of  stout  leather  or  wood  and 
is  fixed  to  the  sole  of  the  boot, 
which  should  be  of  the  shape 
shown  in  the  figure.  The  great  toe 
is  thus  confined  in  a  compartment 
from  which  it  cannot  escape,  and 
no  lateral  deflection  is  permitted. 
(Cheyne.) 


Fig.  374. — Pledget  of  Gauze  Arranged 
to  Overcome  Tendency  to  Recur- 
rence of  Hallux  Valgus,  after 
Operation. 


FLAT-FOOT 

Flat-foot  is  exceedingly  liable  to 
recur  after  operative  correction. 
In  most  instances  operative  meas- 
ures of  relief  are  followed  by  pla- 
cing the  foot  in  the  over-corrected 
position  and  immobilizing  it  in 
plaster-of-Paris  for  six  week-  (Fig. 
376).  A  window  is  cu1  in  tliocast 
on  the  third  day  after  the  operation 
corresponding    in    extent    to    the 


594 


OPERATIONS    ON   THE   EXTREMITIES 


wound.  The  dressing  is  changed  as  frequently  as  is  necessary  with- 
out disturbing  the  position  of  the  foot.  At  the  end  of  the  six  weeks 
of  immobilization  the  cast  is  removed"  and  provision  is  made  for 
obviating  recurrence  of  the  deformity.     A  suitable  steel  spring  is 


Fig.  376.— Markedly  Rigid  Flat  Feet  put  up  in  a  Corrected  Position  in  Circu- 
lar Gypsum  Splints.     (Foote.) 


worn  in  the  shoe  (Fig.  377).  The  "  artificial  arch"  is  made  of 
steel  or  aluminium,  the  latter  being  preferable  as  less  influenced 
by  moisture  than  the  former.  Fig.  377A  shows  a  lateral  view  of 
the  appliance,  Fig.  377B  shows  the  spring  from  the  plantar  sur- 


FLAT-FOOT 


595 


face.     When  the  support  is  fitted  to  the  foot,  it  should  be  molded 
so  as  to  extend  forward  almost  to  the  ball  of  the  foot,  outward 


Fig.  377. — Whitman's  Spring  for  Flat  Feet.  A,  The  splint  is  seen  from  the  inner 
side  applied  to  the  foot,  it  shows  the  prolongation  upward.  In  B,  the  splint 
is  shown  from  below,  and  shows  the  extent  of  the  spring  in  front,  behind  and  exter- 
nally.     (Cheyne.) 


to  the  outer  edge  of  the  foot,  and  backward  to  just  in 
front  of  the  tuberos- 
ity of  the  os  calcis. 
The  foot  plate  ap- 
pears as  shown  in 
Fig.  378,  as  modeled 
by  Hoffa.  The  outer 
edge  of  the  appliance 
is  slightly  raised  to 
keep  the  foot  from 
slipping  laterally. 
The  appliances  in- 
strument makers  car- 
ry in  stock  should 
not  be  employed,  but 
each    foot    must    be 

held  in  the  corrected  position  while  a  mold  is  made  and  the  ap- 
pliance made  to  fit  this. 

In  addition  to  this,  a  specially  constructed  shoe  should  be 
worn.  Fig.  379  shows  a  boot  which  is  of  great  service  in  achiev- 
ing the  purpose.  The  heel  of  the  foot  is  carried  forward  on 
the  inner  side  of  the  shoe  until  it  meets  the  front  part  of  the 
sole.      The  sole   and  heel  are  made  thicker   on  the   inner   side, 

so  as  to  raise  the  inner  border  of  the  foot.      This   causes  the 
40 


Fig.  378. — Lateral  and  Inferior  View  of  Hoffa's 
Foot  Plate  for  Flat-foot,     (von  Bergmann.') 


596 


OPERATIONS   ON  THE   EXTREMITIES 


patient    to    walk    with    the    toes    turned    inward    and    aids    in 
the    intent. 

It  is  probable  that  comparative  weakness  of  the  muscles  of 
the  leg  have  a  bearing  on  the  deformity.  The  patient  is  in- 
structed to  raise  himself  on  his  toes  ten  to  twenty  times  twice 
daily,  and  this  exercise  is  increased  until  he  is  able  to  raise  him- 
self in  the  manner  stated  a  large  number  of  times  at  a  sitting. 


c€%. 


Fig.  379. — Boots  for  Flat-foot.  In  A  is  shown  the  obliquity  of  the  heel  as  seen 
from  the  back.  In  B  the  boot  is  seen  from  below  and  both  the  obliquity  of  the  heel 
and  the  filling  up  of  the  arch  of  instep  by  carrying  the  heel  forward  to  meet  the  sole 
are  shown.  The  prolongation  of  the  heel  forward  is  oblique  in  the  same  direction 
as  the  heel,  it  is  represented  by  the  unshaded  area  in  front  of  the  heel  in  C,  which  is 
a  view  of  the  inner  side  of  the  boot.      (Modified  from  Hoffa.)     (Cheyne.) 


He  should  also  attempt  to  walk  on  the  outer  aspect  of  the  foot 
while  barefooted.  As  the  result  of  continued  immobilization, 
while  the  operative  wound  is  healing,  the  muscles  of  the  leg  un- 
dergo a  certain  degree  of  disuse  atrophy,  and  the  operative  meas- 
ures of  relief  employed  will  fail  in  their  purpose  unless  the  sug- 
gestions offered  or  some  modification  of  them  be  assiduously  car- 
ried out  after  the  operation.  The  support  and  the  conformation 
of  the  shoe  are  of  course  mechanical  measures.  The  shoe,  per- 
haps, tends  to  cause  a  genuine  correction.  However,  the  de- 
formity must  be  overcome  as  the  outcome  of  proper  exercises,  a 
fact  which  must  be  borne  in  mind.  Immediately  after  the  opera- 
tion, massage  and  manual  correction  movements  may  be  employed, 


CLUB-FOOT 


597 


and,  especially  in  young  children,  will  be  found  of  considerable 
service.  Fig.  380  shows  the  position  which  the  manipulations 
should  aim  at. 


Fig.  380. — Manipulation  to  Overcome  Recurrence  of  Flat-foot  after  Correc- 
tion.    (Foote.) 


CLUB-FOOT 

Club-foot  may  be  regarded  in  the  same  light  as  to  after-treat- 
ment as  applies  to  flat-foot.  Indeed,  the  ultimate  outcome  is 
greatly  dependent  upon  persistent  exercise  and  manual  correction. 
Immediately  after  division  of  the  restraining  contractures  the 
foot  may  be  put  up  in  the  manner  shown  in  Fig.  881.  The 
dressing  consists  of  a  piece  of  wood  of  suitable  size  and  thick- 
ness, such  as  the  lid  of  a  cigar  box,  long  enough  to  extend 
from  the  heel  to  at  least  three  inches  beyond  the  tip  of  the  toes, 
which  is  cut  to  the  shape  of  the  foot.  A  piece  of  strapping  be- 
tween two  and  three  inches  broad,  and  sufficiently  long  to  reach 
from  the  middle  of  the  thigh  to  the  toes  and  then  twice  the  length 
of  the  splint,  is  first  applied  to  the  upper  surface  of  the  splint, 
beginning  near  its  anterior  extremity,  carried  along  the  upper 
surface,  round  the  posterior  edge,  and  then  along  the  lower  and 


598 


OPERATIONS   ON  THE   EXTREMITIES 


over  the  anterior  edge  again.  This  part  of  the  strapping  is  then 
firmly  incorporated  with  the  splint  by  means  of  two  or  three 
transverse  pieces  of  strapping  (Fig.  381).     Upon  the  splint  thus 


Fig.  381. — Sayre's  Apparatus  for  Use  after  Tenotomy  of  Tendo-A  chillis.-    The 
smaller  cut  shows  the  method  of  attaching  the  strapping  to  the  foot  splint.  (Cheyne.) 


prepared  are  laid  two  or  three  thicknesses  of  boric  lint,  so  as  to 
form  a  padding,  and  the  splint  is  then  fastened  at  the  heel,  sandal- 
wise,  by  a  broad  strip  of  strapping  passing  aronnd  the  instep  and 
the  posterior  part  of  the  splint  to  the  front  of  the  foot ;  the  splint 
is  then  secured  to  the  foot  by  an  ordinary  bandage.  The  long 
piece  of  strapping  which  now  hangs  over  from  the  front  of  the 
splint  is  next  carried  np  along  the  anterior  surface  of  the  thigh, 
the  foot  meanwhile  being  held  at  right  angles,  and  the  knee  in 
the  fully  extended  position.  The  strapping  is  applied  to  the 
limb  and  fastened  in  position  by  a  bandage,  which  commences 
just  beneath  the  patella  and  is  carried  up  to  about  the  center  of 
the  thigh.  The  free  upper  end  of  the  strapping  is  then  turned 
down,  and  the  bandage  carried  downward  over  it ;  in  this  way  the 
strapping  is  thoroughly  incorporated  with  the  bandage,  and  both 
are  firmly  fastened  to  the  skin  of  the  thigh.  Should  the  strap- 
ping slip,  as  it  frequently  does  after  two  or  three  days,  it  is  not 
necessary  to  apply  fresh  strapping  in  order  to  tighten  it,  but  a 


CLUB-FOOT 


599 


second  bandage  may  be  applied  over  the  old  one,  and  carried 
down  farther  below  the  patella ;  this  will  keep  the  strapping  tant. 
The  patient  should  be  encouraged  to  walk  wearing  this  appara- 
tus. The  effect  of  this  is  that,  as  the  splint  is  longer  than  the 
foot,  considerable  leverage  is  exerted  upon  the  ankle  joint,  and 
the  latter  is  well  bent  as  the  patient  walks.  The  flexion  is  far 
more  effectually  carried  out  than  if  the  foot  were  simply  incased 
in  a  shoe.  By  the  use  of  this  apparatus,  also,  the  calf  muscles 
are  left  free,  and  massage  can  be  applied  to  them.  The  apparatus 
will  generally  require  renewal  about  once  a  week.      {Cheyne.) 

Plaster-of-Paris  will  also  be  found  the  serviceable  material 
for  the  purpose,  being  eas- 
ily applied  and  holding 
firmly  the  parts  in  position. 
Immobilization  should  be 
maintained  for  three 
weeks,  at  which  time  the 
dressing  is  removed  and 
the  patient  subjected  to 
massage,  and  is  encour- 
aged to  freely  move  the 
foot. 

A  tendency  to.  recur- 
rence of  the  deformity  will 
be  noted  soon  after  the 
plaster  is  removed.  To 
overcome  this  the  patient 
is  made  to  wear  a  boot  of 
especial  construction  (Fig. 
382).  It  will  be  seen  that 
the  boot  is  furnished  with 
a  brace  fastened  about  the 
leg  by  means  of  a  padded 
strap ;  a  spring  forces  the 
foot  in  the  position  shown 
by  the  dotted  outline.  The 
shoe  must  be  consider- 
ably longer  than  the  foot.  The  apparatus  stretches  continu- 
ously the  tendon  and  fascia,  and  the  heel  conies   in  contact  with 


Fig.  382. — Boot  for  Use  after  Tenotomy 
of  Tendo-Achillis.  The  dotted  line  shows 
the  position  the  boot  tends  to  assume  when 
the  foot  is  off  the  ground.  It  thus  con- 
tinuously stretches  the  Tendo-Aohillis.  The 
boot  should  be  made  a  good  deal  longer 
than  the  foot,  and  it  should  have  a  stop  at 
the  ankle-joint  hinge  to  prevent  the  toes 
being  pointed.     (//<>//« — Cheyne.) 


600  OPERATIONS    ON   THE   EXTREMITIES 

the  ground  as  the  patient  walks.  It  must  not  be  considered  that 
the  apparatus  will  permanently  cure  the  condition;  on  the  con- 
trary, the  spring  takes  the  place  of  the  flexors  of  the  foot,  and  as 
the  ultimate  outcome  is  dependent  upon  the  resumption  of  con- 
tractility of  the  anterior  group  of  muscles  which  have  long  been 
comparatively  useless,  it  is  patent  that  systematic  massage  and 
exercise  of  these  muscles  must  be  carried  out.  Indeed,  the  pa- 
tient must  be  taught  to  exercise  the  flexor  muscles  without  the 
aid  of  any  artificial  apparatus,  and  the  brace  should  be  discon- 
tinued as  soon  as  possible. 

Of  course  the  muscles  of  the  calf  are  more  largely  used  in  the 
daily  functions,  and  for  this  reason  special  forms  of  exercise  other 
than  locomotion  must  be  employed.  For  the  purpose  a  rowing 
machine  with  a  sliding  seat  or  similar  device  which  compels  the 
patient  to  pull  the  body  forward  by  the  anterior  tibial  muscles 
will  be  found  exceedingly  useful. 

OSTEOTOMY 

Osteotomy  for  bow-legs  or  knock-knees  is  followed  by  immo- 
bilization of  the  parts  in  the  corrected  position  for  six  weeks. 
Immobilization  is  achieved  by  various  forms  of  splints.  How- 
ever, it  will  be  found  that  plaster-of-Paris  is  the  most  useful  agent 
for  the  purpose.  The  wound  of  approach  to  the  site  of  bone  sec- 
tion is  rarely  infected,  and  though  horsehair  or  silk-worm  gut 
drainage  may  be  employed,  the  drainage  agent  may  be  withdrawn 
from  the  wound  on  the  third  day  following  the  operation,  through 
a  window  cut  into  the  plaster  corresponding  to  the  wound.  The 
wound  is  then  redressed  and  the  sutures  removed  •  on  the  tenth 
day.  In  most  instances  it  will  not  be  necessary  to  disturb  again 
the  dressings  until  the  immobilizing  apparatus  is  removed. 

Should,  however,  infection  of  the  wound  occur,  it  may  be 
treated  through  the  window  in  the  plaster  cast,  already  men- 
tioned, without  the  disturbance  of  the  fractured  bones  which  ob- 
tains when  splints  are  used,  the  latter,  of  course,  having  to  be  re- 
moved for  the  purpose. 

As  osteotomy  for  deformity  is  usually  done  in  cases  where 
there  is  a  certain  pathological  condition  of  the  bones,  the  patient 
should  be  confined  to  the  bed  for  several  weeks  after  union  has 


RESECTION   AND   EXCISION   OF   JOINTS 


601 


taken  place,  and  the  diet  be  arranged  with  the  view  of  obviating 
the  constitutional  fallacy.  The  phosphates  of  lime  and  soda,  to- 
gether with  general  tonics,  should  also  be  administered.  In  young 
adults  it  is  well  to  supplement  the  treatment  stated  with  the  ap- 
plication of  an  apparatus  which  will  tend  to  obviate  recurrence  of 
the  deformity.  For  the  purpose,  in  cases  where  knock-knee  has 
been  corrected,  an  apparatus,  such  as 
shown  in  Fig.  383,  may  be  used.  The 
joint  in  the  iron  brace  permits  of  flexion 
of  the  knee,  and  a  similar  one  at  the 
ankle  joint  permits  of  motion  in  the  lat- 
ter. These  provisions  are  essential  to 
conserving  muscular  tone.  The  traction 
is  made  at  the  various  points  shown  in 
the  illustration.  The  apparatus  should 
be  worn  for  several  months  following  the 
operation. 

After  correction  of  bow-legs  a  sil- 
icate of  soda  splint  may  be  worn  for 
several  weeks  following  the  operative 
relief.  The  splint,  however,  should  not 
include  either  the  knee  or  ankle  joints. 

As  exercise  of  the  muscles  of  the 
limb  while  held  in  a  normal  position  is 
essential  to  ultimate  success,  the  appara- 
tus should  be  worn  during  locomotion, 
and  supplemented  with  exercises  while 
the  patient  is  in  the  sitting  posture.   The 

practitioner  must,  bear  in  mind  that  the  deformity  of  bones  is 
simply  a  symptom,  and  the  constitutional  treatment  must  be  des- 
tined to  correct  the  fallacy.  Again,  the  simple  correction  of  the 
deformity  must  be  supplemented  by  protracted  employment  of 
massage  and  exercise  in  order  to  achieve  a  favorable  ultimate 
result. 


Fig.  383. — Apparatus  for 
Bow-legs.     (Dennis.) 


RESECTION   AND    EXCISION   OF   JOINTS 


Resection  and  excision  of  joints,  if  done  for  the  purpose  of 
correcting  deformity,  or  to  achieve  motility  of  joints  following 


602  OPERATIONS    ON   THE   EXTREMITIES 

afflictions  which  have  healed,  are  succeeded  by  complete  closure 
of  the  wound  and  immobilization  of  the  parts  until  the  wound  is 
healed.  Drainage  is  not  employed  in  these  cases  unless  for  special 
indications,  such  as  persistent  oozing  of  blood,  or  because  of  ex- 
tensive trauma  to  the  parts.  For  the  purpose  the  limb  is  held 
quiescent  by  means  of  splints,  which  latter  are  applied  over  the 
usual  protective  dressing.  For  the  purpose  of  immobilization, 
plaster-of-Paris  or  silicate  of  soda  will  be  found  most  serviceable. 
If  drainage  has  been  employed,  a  window  corresponding  to  the 
wound  area  is  cut  into  the  incasing  immobilization  apparatus, 
and  the  drain  is  removed  on  the  third  day  following  the  operation. 
Seven  days  later  the  wound  is  again  exposed  and  the  sutures  re- 
moved from  the  wound.  Of  course,  when  absorbable  suture  ma- 
terial has  been  employed,  the  latter  step  need  not  be  taken.  If  no 
drainage  has  been  introduced  into  the  wound,  and  there  be  no 
evidence  of  infection,  the  wound  need  not  be  disturbed  until  the 
tenth  clay,  when  the  sutures  are  removed.  At  the  time  that  the 
drainage  is  removed,  the  dressing  is  made  under  strict  aseptic 
precautions.  When  the  sutures  are  removed  and  there  be  no 
evidence  of  infection  expressed  by  pain,  rise  of  temperature,  etc., 
the  precautions  with  respect  to  asepsis  are  likely  to  be  disregarded. 
The  practitioner  is  warned  against  laxity  in  this  connection,  as 
late  infection  may  occur  as  the  outcome  of  neglect  in  this  regard. 

A  moderate  degree  of  infection  is  very  likely  to  occur  follow- 
ing resection  of  joints,  due,  perhaps,  to  the  fact  that  parts  which 
have  been  restricted  with  respect  to  motility  do  not  seem  to  have 
the  same  degree  of  resistance  to  the  invasion  of  infective  proc- 
esses as  obtains  when  the  normal  physiological  functions  have 
been  impaired  only  for  a  short  period  of  time. 

Immobilization  of  a  limb  following  resection  of  a  joint  should 
not  be  maintained  longer  than  is  necessary  to  accomplish  repair 
of  the  wound.  The  process  of  healing  is  in  many  regards  quite 
similar  to  that  of  the  affliction  which  caused  the  pathological  con- 
dition for  the  relief  of  which  operative  measures  are  undertaken. 
If  no  infection  exist  at  the  time  of  the  operation,  passive  motion 
should  be  employed  as  soon  as  repair  of  the  wound  is  sufficiently 
advanced  to  justify  its  use.  Indeed,  it  is  probable  that  joints 
which  have  been  subjected  to  operative  attack  should  not  be  held 
quiescent  for  more  than  three  weeks  and  passive  motion  should 


RESECTION   AND   EXCISION   OF   JOINTS  603 

be  employed  at  this  time,  even  though  complete  repair  of  the 
wound  is  not  yet  attained.  In  instances  in  which  no  infection  ex- 
ists at  the  time  of  the  operation  and  relief  of  impaired  useful- 
ness, the  outcome  of  repair  following  injury,  is  aimed  at,  passive 
motion  may  be  begun  from  the  day  upon  which  the  sutures  are 
removed. 

When  passive  motion  is  begun,  the  original  cast  is  cut  down 
and  a  second  lighter  one  applied.  This  is  cut  down  immediately, 
that  is,  before  the  plaster  is  quite  hard  and  a  light  gauze  bandage 
made  to  hold  the  sectioned  cast  in  place.  The  splint  is  removed 
daily,  the  wound  dressed,  and  the  limb  subjected  to  passive  mo- 
tion. In  the  meantime,  the  patient  is  encouraged  to  move  actively 
the  parts  of  the  limb  contiguous  to  the  joint  immobilized,  with 
the  view  of  facilitating  nourishment  and  return  of  function.  As 
soon  as  repair  is  complete,  the  patient  begins  to  use  the  limb,  re- 
moving the  cast  for  the  purpose  for  several  hours  each  day  and 
reapplying  it  at  night.  In  this  way  a  certain  degree  of  recur- 
rence of  the  deformity,  which  is  very  liable  to  occur,  is  obviated. 
During  this  time  the  patient  is  to  be  kept  under  observation  and, 
if  necessary,  the  apparatus  worn  at  night  should  be  so  constructed 
as  to  overcome  any  tendency  toward  deformity  or  ultimate  limi- 
tation of  motion. 

Ankylosis  after  resection  of  joints  is  aimed  at  in  the  knee- 
joint.  In  these  cases  the  femur  and  tibia  are  held  in  apposition, 
with  the  view  of  attaining  union  between  the  two  bones,  either  by 
means  of  apparatus  or  by  the  introduction  of  various  agents,  such 
as  wire  or  pegs  or  nails.  In  this  class  of  cases  the  immobilization 
is  maintained  until  union  is  complete,  which  requires  from  six  to 
eight  weeks.  However,  the  wound  is  treated  in  much  the  same 
way  as  are  the  wounds  in  other  portions  of  the  body.  When  in- 
fection exists  at  the  time  of  the  operation,  such  as  obtains  with 
joint  tuberculosis,  drainage  is  invariably  employed,  and  the 
wound  will  have  to  be  treated  for  a  considerable  period  of  time. 

As  regards  the  knee  joint,  the  character  of  dressing  which 
makes  accessible  the  wound  while  union  of  the  bones  takes  place, 
is  similar  to  that  following  resection,  when  infection  exists,  and 
will  be  described  under  one  head.  Fig.  384  shows  an  apparatus 
which  is  of  service  in  both  classes  of  cases.  The  leg  is  incased 
in  plaster-of-Paris,  which  is  carried  upward  posteriorly  support- 


604 


OPERATIONS    ON   THE   EXTREMITIES 


ing  the  popliteal  space.  The  thigh  is  also  incased  in  the  same 
material,  as  shown  in  the  illustration.  After  a  few  layers  of 
plaster-of-Paris  bandages  have  been  applied,  a  stout  steel  wire, 


Fig.  384. — Suspended  Bracketed  Plaster-of-Paris  Splint.     {Bryant.) 

bent  in  the  fashion  shown  in  the  illustration,  is  applied  to  the-  an- 
terior aspect  of  the  limb,  and  is  buried  by  successive  layers  of 
plaster-of-Paris  bandages,  leaving  uncovered  the  portions  shown 


Fig.   385. — Bracketed   Suspended   Plaster-of-Paris   Splint  for   Excision   of 
Ankle  Joint.     {Bryant.) 

exposed  in  the  picture.  The  limb  may  be  swung  by  means  of 
cords  from  a  pulley  fastened  above  the  bed.  The  region  of  the 
joint  and  the  wound  are  thus  made  readily  accessible,  and  the 


RESECTION    AND    EXCISION    OF   JOINTS 


605 


dressing  may  be  frequently  changed  and  the  wound  treated  with- 
out disturbance  of  the  relationship  of  the  bones. 

A  similar  device  applied  to  the  ankle  joint  is  shown  in  Fig. 
385.     Fig.  386  shows  the  same  principle  applied  to  the  wrist.     In 


-^-*V,'.4Jj.ij|iijJ>' 


Fig.  386. — Bracketed  Suspended  Plaster-of-Paris  Splint  for  Excision  of  Wrist 

Joint.     {Bryant.) 

cases  of  this  sort,  the  joints  contiguous  to  the  afflicted  one  are  also 
immobilized  as  muscles  which  animate  them  cross  the  afflicted 
joint.  Complete  immobilization  of  the  limb  should  not,  however, 
be  maintained  for  more  than  three  weeks,  at  which  time  the  ap- 
paratus is  removed  and  the  immobilization  confined  to  the  afflicted 
joint.  In  joints  where  ankylosis  is  not  aimed  at,  where,  how- 
ever, infection  exists  at  the  time  of  the  operation,  passive  motion 
is  begun  at  the  end  of  three  weeks,  even  though  repair  is  not  quite 
complete.  The  limb  is  incased  in  a  removable  immobilization 
apparatus  which  is  removed  daily,  and  active  and  passive  motion 
is  employed  as  stated  above.  If  the  repair  is  slow,  as  is  likely, 
especially  if  relief  of  joint  tuberculosis  is  undertaken,  the  Bier 
treatment  may  be  applied  for  several  hours  each  night,  the  con- 
striction being  applied  with  the  immobilization  apparatus  in 
place.     There  is  a  tendency  to  unnecessarily  prolong  the  immo- 


606  OPERATIONS    OX   THE    EXTREMITIES 

bilization  of  the  joint.  While  protracted  quiescence  of  tubercu- 
lous joints  which  are  being  conservatively  treated  may  be  justi- 
fiable, it  is  not  indicated  in  cases  in  which  the  tuberculous  disease 
has  been  removed  by  operation,  and  motility  of  the  joint  is  aimed 
at.  During  the  after-treatment  of  cases  of  this  sort,  the  constitu- 
tional treatment  directed  towards  correcting  the  cause  of  the  joint 
affliction  should  be  assiduously  carried  out. 

In  the  treatment  of  the  wound  itself,  it  must  be  borne  in  mind 
that  when  complicating  purulent  infection  does  not  exist  at  the 
time  of  the  operation,  it  is  exceedingly  liable  to  occur  subsequent 
to  the  operation,  and  must  be  avoided  by  adherence  to  the  rules 
of  asepsis.  In  a  measure  the  lessened  resistance  of  the  patient 
makes  mixed  infection  more  likely  to  occur  under  these  circum- 
stances. A  sinus  leading  to  a  small  portion  of  bone  which  is  ex- 
foliating, the  outcome  of  trauma  at  the  time  of  the  operation, 
should  not  be  turned  over  to  the  patient  for  treatment,  unless  he 
happen  to  be  intelligent  enough  to  observe  the  necessary  clean- 
liness. 

AMPUTATIONS 

Amputation  wounds  are,  as  far  as  the  after-treatment  is  con- 
sidered, divided  into  two  kinds.  Those  which  are  left  open,  and 
those  in  which  the  flaps  are  approximated  and  drainage  estab- 
lished. 

The  open  method  of  treating  wounds  following  amputations 
is  employed  in  cases  where  infection  exists  at  the  time  of  the 
operation,  especially  if  the  infection  be  irregular  in  its  extent, 
and  the  remaining  stump  be  the  residence  of  infective  process 
which  does  not  invalidate  the  vitality  of  the  tissues  remaining. 
For  instance,  an  osteomyelitis  involving  the  lower  ends  of  the  fe- 
mur and  extending  into  the  shaft  may  call  for  amputation,  but 
the  bone  section  may  be  made  just  above  the  condyles,  the  shaft 
of  the  bones  scraped  out  and  cleansed,  the  wound  packed  and  ul- 
timately complete  repair  takes  place,  while  at  the  same  time  a 
considerable  extent  of  the  limb  is  saved.  In  these  cases  approxi- 
mation of  the  flaps  by  suture  would  serve  no  useful  purpose,  and, 
indeed,  healing  by  granulation  gives  in  the  end  a  stump  which  is 
in  all  respects  as  serviceable  as  obtains  when  primary  union  is 
achieved,  the  only  disadvantage  being,  perhaps,  that  the  former 


AMPUTATIONS 


607 


method  of  healing  is  a  more  prolonged  one.  However,  the  cer- 
tainty of  removal  of  offending  secretions,  and  the  accessibility  of 
the  parts  to  postoperative  treatment  and  care  argues  strongly  for 
employment  of  the  measure  in  a  certain  class  of  cases. 

When  the  stump  is  treated  by  the  open  method,  the  wound  is 
packed  moderately  firm  with  sterile  gauze  for  forty-eight  hours 
(Fig.  387).     Iodoform  gauze  or  other  so-called  medicated  gauze 


Fig.  387. — Open  Method  of  Treating  Amputation  Wound. 


should  be  used  with  discretion,  as  the  large  raw  surface  it  comes 
in  contact  with  will  absorb  the  medicament  and  poisoning  is  liable 
to  occur.  The  packing  is  left  in  place  no  longer  than  the  two  days 
mentioned,  when  it  is  removed.  When  infection  of  the  deep  parts 
is  present,  firm  packing  interferes  with  drainage  and  the  gauze 
should  be  only  lightly  placed  into  the  wound,  with  sufficient  spaces 
between  the  layers  to  permit  of  egress  of  the  secretions.  In  the 
latter  class  of  cases  the  gauze  may  be  soaked  with  a  solution  of 
carbolic  acid,  1  in  500,  and  the  entire  limb  covered  with  gauze 
saturated  with  the  same  solution.  This  dressing  should  not,  how- 
ever, be  left  undisturbed  for  more  than  twenty-four  hours,  at 
which  time  the  wound  is  cleansed  with  normal  salt  solution,  with 
the  view  of  removing  thoroughly  the  carbolic  acid  solution.     The 


608  OPERATIONS    OX   THE   EXTREMITIES 

stump  should  not  be  treated  with  a  solution  of  carbolic  acid  for 
more  than  a  day,  and  the  second  dressing  should  be  wet  with  saline 
solution,  in  order  to  obviate  the  maceration  and  at  times  slough- 
ing which  attends  the  prolonged  use  of  the  carbolic  acid.  When 
the  gauze  saturated  with  saline  solution  is  removed,  peroxid  of 
hydrogen  may  be  injected  into  the  wound,  with  the  view  of  loosen- 
ing the  gauze  from  the  raw  surfaces,  though  this  measure  is  not  as 
essential  as  in  cases  in  which  dry  gauze  is  introduced  into  the 
wound.  The  stump  is  irrigated  with  a  solution  of  corrosive  sub- 
limate, 1  in  2,000,  all  secretions  are  removed  and  sloughing  tissue 
picked  off  with  dressing  forceps.  The  protective  dressing  should 
be  applied  with  just  sufficient  pressure  to  hold  it  in  place.  Firm 
bandaging  is,  perhaps,  justifiable  for  the  first  twenty-four  hours 
following  the  operation  with  the  view  of  controlling  oozing  of 
blood,  but  should  not  be  maintained  longer  than  this  as  in  cases 
where  infection  is  present.  The  flaps  have  already  lost  some  vi- 
tality as  the  outcome  of  the  pathological  process,  and  should  not 
be  subjected  to  additional  burden  in  this  regard. 

When  the  wound  is  clean,  that  is,  if  no  infection  exists  at  the 
time  of  operation,  such  as  is  the  case  when  the  amputation  is  made 
for  trauma  or  for  the  removal  of  deformed  or  useless  limbs,  the 
flaps  are  approximated  by  suture  and  drainage  is  employed. 

For  the  purpose  silk-worm  gut  may  be  used,  though  at  times 
catgut  is  used.  The  reasons  for  preferring  the  former  in  approxi- 
mating the  skin  has  already  been  mentioned  (page  97).  Drain- 
age with  a  rubber  tube  which  emerges  at  either  angle  of  the  wound 
will  be  found  to  be  the  most  useful  in  this  class  of  cases  (Fig. 
388).  This  arrangement  enables  the  attendant  to  irrigate  through 
and  through  from  either  side,  and  clots  and  secretions  are  readily 
removed.  Textile  fabric  may  be  used  for  the  purpose,  but  does 
not  permit  of  cleansing  of  the  wound  with  the  facility  which  ob- 
tains when  tube  drainage  is  employed.  The  final  dressing  of  the 
stump  in  either  class  of  cases  should  be  supplemented  by  the  ap- 
plication of  a  splint  immobilizing  the  limb  (Fig.  389).  The  limb 
should  also  be  placed  in  a  position  which  obviates  tension  on  the 
flaps,  the  thigh  or  arm  being  supported  by  a  pillow,  and  the  bed- 
clothes kept  from  coming  in  contact  with  the  parts  by  holding 
them  away  by  means  of  an  appropriately  arranged  canopy.  The 
tube  drainage  is  removed  on  the  third  day  following  the  opera- 


AMPUTATIONS 


609 


tion,  provided  infection  has  not  occurred.     If  infection  occurs,  the 
tube  is  changed  and  another  one  introduced,  which  procedure  is 


Fig.   388.— Amputation  Wound  Closed  with  Interrupted  Sutures  and  Tube 
Drainage  Introduced. 

repeated  at  intervals  of  forty-eight  hours  until  the  infection  sub- 
sides, at  which  time  horsehair  or  silk-worm  gut  drainage   (page 


Fig  389.— Amputation  Wound  Dressed,  Stump  Immobilized  on  Posterior  Padded 
Splint  and  Thigh  Extended  to  Relax  Muscles. 

193)  is  used,  until  the  secretion  of  inflammatory  products  ceases 
to  discharge.      If  the   infection  is   severe,   it  is  best  to  remove 


610  OPERATIOXS   ON   THE   EXTREMITIES 

entirely  the  sutures  and  treat  the  case  as  is  described  under  the 
"  open  method  "  of  handling  the  problem. 

A  certain  amount  of  secretion  is  discharged  in  all  instances 
following  amputations.  This  is  a  part  of  the  process  of  repair, 
although  the  character  of  the  discharge  varies  with  respect  to 
whether  pus  is  formed  or  not.  A  part  of  the  secretion  is  due  to 
a  certain  amount  of  superficial  necrosis  of  the  divided  ends  of 
bones,  and,  indeed,  even  in  cases  in  which  primary  union  is  prac- 
tically obtained,  a  small  sinus  corresponding  to  the  point  of  egress 
of  the  drainage  tube  may  persist  for  several  weeks  after  the  opera- 
tion, which  finally  heals  when  the  portion  of  bone  has  been  ex- 
foliated. In  cases  where  infection  exists  at  the  time  of  the  opera- 
tion, a  considerable  degree  of  necrosis  of  bone  usually  follows, 
and  this  may  cause  the  wound  to  remain  open  at  some  point  for 
a  considerable  period  of  time. 

In  clean  cases  it  at  times  happens  that  the  necrosed  bone  does 
not  manifest  itself  until  after  the  superficial  wound  has  healed, 
and  the  case  then  presents  the  signs  and  symptoms  of  inflamma- 
tion. An  incision  made  into  the  inflamed  area  liberating  the 
exudate  and  subsequent  light  packing  will  meet  the  indications. 
Sutures  are  removed  on  the  tenth  day  following  the  operation. 
When  tension  sutures  are  employed  (page  215),  these  are  re- 
moved at  the  same  time. 

If  infection  of  the  superficial  wound  occurs  the  deep  or  ten- 
sion or  relaxation  sutures  need  not  be  removed  until  the  time 
stated,  even  though  it  may  have  been  necessary  to  remove  the 
greater  part  of  the  approximation  sutures.  Of  course,  if  the  en- 
tire surface  of  the  wound  be  infected  and  pus  form  beyond  the 
relaxation  sutures,  these,  too,  must  be  immediately  removed. 
Uninfected  cases  heal  in  about  two  weeks  including  the  drainage 
tube  openings,  which  latter  require  a  little  more  time  for  com- 
plete healing  than  obtains  with  respect  to  the  rest  of  the  wound. 

When  healing  is  complete,  either  in  the  cases  in  which  the 
open  method  or  closure  of  the  wound  has  been  practiced,  the  limb 
is  incased  in  a  light  dressing,  and  the  contiguous  joint  is  sub- 
jected to  progressive,  passive,  and  active  motion. 

Systematic  massage  of  the  healed  stump  should  be  begun  as 
soon  as  feasible.  The  patient  is  instructed  to  subject  the  stump  to 
frequent  handling  and  manipulations  with  the  view  of  creating 


AMPUTATIONS  611 

a  tolerance  for  the  pressure  of  an  artificial  appliance.  For  the 
purpose  lanolin  or  vaselin  may  be  used  and  the  skin  is  bathed  with 
soap  and  water  and  sponged  with  alcohol,  after  which  a  dusting 
powder  of  bismuth  or  similar  agent  is  applied. 

There  is  no  fast  and  hard  rule  applicable  to  what  time  an 
artificial  limb  may  be  applied.  On  general  principles  it  may  be 
said  that  as  soon  as  the  manipulations  mentioned  are  well  borne, 
the  artificial  appliance  may  be  used  for  a  certain  period  of  time 
each  clay  and  discarded  when  evidence  of  irritation  appears.  As 
soon  as  pain  and  redness  appears  the  apparatus  must  be  laid 
aside  and  the  skin  treated  in  the  manner  stated  until  the  irrita- 
tion disappears,  when  the  artificial  limb  is  again  applied.  Toler- 
ance for  the  peculiar  condition  of  affairs  will  soon  be  established. 
Under  no  circumstances  should  an  attempt  be  made  to  force  the 
situation  by  persistence  in  wearing  the  apparatus  in  the  presence 
of  irritation  of  the  stump. 

As  soon  as  the  patient  convalesces  he  should  be  encouraged 
to  go  about.  When  the  lower  extremity  has  been  in  part  or  en- 
tirely removed,  the  patient  will  be  compelled  to  use  crutches  for 
some  time,  while  the  stump  is  prepared  for  an  artificial  appli- 
ance. Locomotion  with  crutches  should  contemplate  coordination 
with  the  lessened  parts  concerned  in  it.  This  is  not  always  ration- 
ally attempted.  Even  though  an  artificial  appliance  is  to  be  used, 
the  training  with  crutches  is  essential  in  order  to  cause  a  certain 
compensatory  hypertrophy  of  the  remaining  limb  and  to  estab- 
lish a  new  sense  of  balance.  For  the  purpose  the  crutch  should 
be  so  constructed  as  to  permit  of  locomotion  without  undue  pres- 
sure upon  the  axilla.  Most  of  the  weight  should  be  borne  by  the 
hands  which  grasp  the  crutch  at  such  a  distance  from  the  axilla 
as  to  obtain  the  desired  condition  of  affairs.  Failure  to  instruct 
the  patient  in  this  regard  causes  pressure  upon  the  brachial 
nerves,  chiefly  the  musculo-spiral,  giving  rise  to  a  condition  known 
as  "  crutch  paralysis."  This  is  an  exceedingly  distressing  occur- 
rence and  should  be  avoided. 

The  additional  advantage  of  early  locomotion  is  the  greater 
rapidity  with  which  patients  regain  a  normal  general  condition, 
to  which  may  be  added  the  improvement  in  the  mental  condition 
as  the  outcome  of  resumption  of  some  occupation. 

41 


CHAPTEK    XXXIII 

ARTIFICIAL   LIMBS 

Instep  amputations — Retracted  heels — Ankle-joint  amputations — -Leg  ampu- 
tations— Knee-bearing  stumps — Thigh  stumps — Hip-joint  amputations — 
Amputations  of  upper  extremities. 

With  respect  to  artificial  appliances  to  the  stumps  following 
amputations  of  the  lower  limbs  it  is  necessary,  in  order  to  have 
an  intelligent  conception  of  the  rationale  of  the  apparatus,  to  be 
acquainted  with  the  mechanism  of  locomotion. 

Kinetoscopic  photography  has  been  an  exceedingly  valuable 
aid  in  the  study  of  the  actions  of  the  knee  and  ankle  joints  dur- 
ing locomotion.  The  conclusions  arrived  at  would  seem  to  jus- 
tify the  belief  that  a  person  walking  at  the  rate  of  two  miles  an 
hour  flexes  the  knee  but  slightly  and  the  ankle  considerably. 
When  walking  at  the  rate  of  three  miles  an  hour,  the  knee  joint 
acts  through  a  greater  range  and  the  ankle  joint  through  a  lesser 
one.  When  walking  with  moderate  speed,  say  at  the  rate  of  four 
miles  an  hour,  the  knee  action  becomes  considerable  and  the  ankle 
action  scarcely  perceptible.  When  walking  rapidly,  say  five  miles 
an  hour,  the  knee  action  is  increased  and  the  ankle  becomes  prac- 
tically rigid.  When  running,  the  knee  increases  its  action  and  the 
ankle  reverses  its  action  and  throws  the  pedestrian  forward  by 
the  ball  of  the  foot. 

The  ratio  between  the  range  of  motion  of  the  knee  and  ankle 
joints  is  in  proportion  to  rapidity  of  the  act  of  locomotion.  An 
impulse  to  walk  slowly  or  rapidly,  or  to  change  from  one  gait 
to  another,  is  formulated  in  the  pedestrian's  mind,  this  is  conveyed 
to  the  muscles  of  the  limbs,  which  act  is  in  accord  with  the  impulse. 
A  person  whose  muscles  do  not  respond  in  accord  with  the  mind 
becomes  incoordinate  in  his  gait.  If  an  artificial  leg  be  sup- 
plied with  an  ankle  joint  which  is  not  under  control  of  the  will, 

612 


ARTIFICIAL   LIMBS  613 

the  wearer  is  in  much  the  same  position  as  a  person  afflicted  with 
ataxia. 

Three  miles  an  hour  is  the  rate  at  which  the  average  person 
walks.  Successive  photographs  of  a  man  walking  at  this  gait  show 
that  there  is  but  little  motion  in  the  ankle  joint  and,  limited  as 
it  is,  it  is  of  a  character  which  can  not  be  imitated  by  mechanical 
means. 

Artificial  feet  with  ankle  joints  set  to  act  at  a  constant  range 
of  motion  allows  the  wearer  to  walk  fairly  well  at  a  slow  rate  of 
speed,  but  at  a  speed  of  three  or  more  miles  an  hour,  the  step 
becomes  perceptibly  awkward,  and  the  effort  required  to  overcome 
the  too  liberal  motion  in  the  ankle  is  fatiguing.  So  far  as  the 
knee  joint  is  concerned,  the  motions  of  the  artificial  and  natural 
legs  are  approximately  the  same,  but  the  motions  of  the  ankles 
are  very  different.  The  sole  of  the  foot  is  flat  on  the  ground  for 
a  considerably  longer  period  of  time  with  the  artificial  ankle  joint, 
than  obtains  with  the  natural  one.  As  the  walker  advances  and 
strikes  the  heel  of  the  artificial  foot  on  the  ground,  almost  imme- 
diately the  front  of  the  foot  drops  and  the  entire  sole  rests  on 
the  ground  and  remains  there  during  the  interval  through  which 
the  body  passes  over  it. 

A  person  walking  with  natural  feet  throws  the  left  foot  for- 
ward, barely  touching  the  heel  to  the  ground.  Instantly  the 
right  foot  under  control  of  the  tendo- Achilles  extends  and  the  heel 
is  raised  from  the  ground,  throwing  the  weight  of  the  body  on  the 
ball,  supplying  the  impetus  that  urges  the  body  forward.  As  the 
body  is  carried  forward,  the  ball  of  the  foot  reaches  the  ground  at 
about  the  time  the  body  is  vertically  over  it.  At  this  point  the 
right  foot  is  in  the  act  of  leaving  the  ground,  and  is  passing  the 
left  which,  still  being  flat  on  the  ground,  performs  no  function, 
except  that  of  supporting  the  body.  The  right  leg  is  carried  a 
little  farther  forward  when  a  slight  amount  of  flexion  occurs  in 
the  left  ankle  joint.  But  this  is  quite  transient.  The  tendo- 
Achilles  instantly  contracts  and  the  foot  extends,  the  entire  body 
is  lifted  and  thrown  on  the  ball  of  the  foot,  and  when  the  weight 
of  the  body  is  placed  on  the  heel  of  the  right  foot,  there  is  a  slight 
flexion  in  the  knee-joint  which  permits  the  sole  to  reach  the  ground. 
At  this  time  the  knee-joint  of  the  left  foot  is  flexed  and  the  foot 
of  that  leg  is  raised,  and  when  the  weight  of  the  body  is  practi- 


614 


ARTIFICIAL   LIMBS 


cally  over  the  right  foot,  the  knee  is  extended,  so  as  to  support  the 
weight  securely. 

Artificial  feet  without  ankle  joints  when  supplied  with  rubber 
cushions  and  the  so-called  "  spring-mattress  "  are  capable  of  imitat- 
ing more  closely  the  natural  mechanism  of  locomotion  than  obtains 
with  those  supplied  with  artificial  ankle  joints.  As  the  walker 
advances  on  the  rubber  foot,  he  touches  the  heel  to  the  ground,  the 
weight  is  applied,  and  the  sponge  rubber  in  the  heel  compresses 
sufficiently  to  allow  him  to  roll  on  the  bottom  of  the  foot.  The 
moment  the  body  is  carried  a  little  in  advance,  he  rises  on  the  ball 
very  much  the  same  as  he  does  on  the  natural  foot. 

The  studies  mentioned  would  show  that  the  artificial  foot  fur- 
nished with  an  ankle  joint  remains  longer  on  the  ground  during  the 
act  of  locomotion  than  is  desirable,  and  that  an  artificial  foot  with 
a  rigid  ankle  joint  and  the  foot  itself  constructed  of  elastic  mate- 
rial imitates  more  closely  the  mechanism  of  locomotion  and,  there- 
fore, preferable.  Practical  observation  seems  to  bear  out  this 
notion.  The  normal  foot  is  an  exceedingly  complicated  mechan- 
ism. This  can  in  no  sense  be  duplicated  by  mechanical  means. 
The  office  of  the  artificial  foot  is  to  supply  a  means  of  locomotion 
only,  and  with  this  principle  in  mind,  the  studies  quoted  above 
permit  of  a  conclusion  which  is  valuable. 

The  artificial  foot  as  alluded  to  seems  to  be  of  sufficient  im- 
portance in  connection  with  the  problem  to  warrant  an  extended 
description.  The  appliance  is  the  outcome  of  the  ingenuity  of 
A.  A.  Marks  of  New  York  who  describes  his  product  substantially 
as  follows: 


The  rubber  foot  consists  of  a  wooden  core,  carved  to  size  and  shape 
to  secure  the  best  results  (Fig.  390).  The  faint  lines  in  the  illustra- 
tion represent  the  core 
which  reaches  the  ball  of 
the  foot,  localizing  the  toe 
movement.  The  distance 
from  the  core  to  the  floor 
at  the  heel  is  consider- 
ably greater  than  at  any 
other  part ;  this  is  done 
a.  a.  marks,  n.  v  ^0  obtain  the  proper  de- 

Fig.  390. — Profile  View  of  Rubber  Foot.  gree  of  compressibility  at 


ARTIFICIAL   LIMBS 


615 


A-  A.  MARKS,  N.  Y. 


Fig.  391. — Spring  Mattress  for  Rubber  Foot. 


the  heel.  The  core  is  entirely  surrounded  with  rubber  of  great  porosity 
which  will  yield  under  the  weight  of  the  wearer  sufficiently  to  make 
the  step  realistic.  Less  rubber  is  placed  at  the  ball  so  as  to  provide 
phalangeal  support  and  create  a  supporting  medium  at  the  front  of 
the  foot,  ample  to  steady  him  when  standing,  and  to  act  as  a  lever 
when  walking.  A  spring  mattress  is  floated  in  the  foot  below  the 
core,  covering  the  entire  distance  from  the  back  of  the  heel  to  the 
tips  of  the  toes,  as 
shown  b}'  the  lines  run- 
ning lengthwise  in  the 
illustration  (Fig.  391). 
The  spring  mattress  is 
formed  by  a  series  of 
composition  strips  em- 
bedded in  strong  sail 
duck,  each  having  a  pocket  of  its  own  (Fig.  391),  the  strips  occupying 
the  pockets  a,  a,  a,  a. 

The  spring  mattress  is  a  device  intended  to  give  additional  re- 
silience for  both  toes  and  heel.  Every  movement  of  the  foot  when  in 
action,  applies  pressure  to  the  springs  at  the  heel,  ball,  or  on  the  sides. 
The  counteracting  tendency  of  the  strips  aids  in  forcing  the  foot  back 
to  its  proper  shape  as  soon  as  pressure  is  removed. 

Fig.  392  shows  the  rubber  foot  with  the  weight  applied  to  the  ball 

as  it  is  when  the  wearer 
is  being  urged  forward 
while  walking.  The 
spring  mattress  is  now 
forced  upward  at  the 
ball  and  the  sponge  rub- 
ber is  compressed  above 
and  below  the  mattress. 
This  pressure  pulls  the 
mattress  forward  in  the 
foot.  These  movements 
— the  yielding  of  the 
spring,  the  compression 
of  the  rubber,  and  the 
pulling  of  the  spring  mattress  forward — form  a  very  powerful  result- 
ant force  that  brings  the  foot  back  to  its  original  lines  as  soon  as  the 
foot  is  relieved  of  weight. 

The  condition  of  the  appliance  when  under  heel  pressure,  as  it  is 
when  the  wearer  places  the  artificial  limb  forward  and  applies  his 


a.  a.  marks,  n.  y. 

Fig.  392. — Position  of  Rubber  Foot  When 
Walking. 


616 


ARTIFICIAL    LIMBS 


weight  upon  it,  is  somewhat  the  same.     The  spring  mattress  is  forced 
upward,  the  sponge  rubber  is  compressed  above  and  below,  the  heel 

becomes  flattened,  and 
the  mattress  being  pulled 
lengthwise,  all  combine 
to  force  the  foot  to  its 
shape  as  soon  as  pressure 
on  the  heel  is  removed. 
The  compression  of  the 
heel  permits  the  toes  and 
the  front  part  of  the  foot 
to  reach  the  ground, 
while  the  shaft  of  the  leg 
is  obliquely  back  of  the 
vertical  line.  Fig.  393 
shows  the  foot  on  an  in- 
clined surface.  On  ac- 
count of  the  yielding  quality  of  the  rubber,  the  up-hill  side  of  the  foot 
will  compress  and  accommodate  itself  to  the  incline  and  allow  the  foot 
to  remain  on  its  base.  This  is  accomplished  without  complicated 
mechanical  lateral  articulation. 

It  can  readily  be  seen  that  any  motion  in  the  ankle  that  cannot  be 
controlled  by  the  will  must  be  mechanical  in  action.  The  approach 
to  the  mechanism  of  locomotion  is  more  positive  by  their  omission. 

INSTEP  AMPUTATIONS 


A.  A.  MARKS.  N.  Y. 


Fig.  393.- 


-Position  of  Rubber  Foot  on 
Inclined  Surface. 


Instep  amputations 
which  include  the  Lisfranc, 
Chopart,  Hays,  Hancock  and 
other  methods  will  be  found 
to  call  for  the  application  of 
some  device  other  than  the 
mere  padding  of  the  shoe,  if 
the  best  possible  kind  of  lo- 
comotion is  to  be  obtained. 
It  is  absolutely  useless  to 
apply  any  form  of  apparatus 
in  these  cases  unless  the  arti- 
ficial appliance  is  held  so 
firmly  that  the  wearer  may 


Fig.  394, 


-Appliance  for  Instep 
Amputation. 


INSTEP   AMPUTATIONS 


617 


Fig.    395. — Appliance   for   In- 
step Amputation  in  Place. 


rise  on  the  ball  of  the  foot,  and  sup- 
port his  weight  while  in  that  position. 
Fig.  394  shows  an  appliance  which 
serves  the  purpose  very  well.  A  half 
leg,  or  front,  including  the  core  of  the 
foot,  is  made  of  aluminium,  without 
articulation  at  the  ankle.  The  rear 
half  is  made  of  leather,  shaped  to  in- 
case the  leg  and  the  aluminium  shell 
and  hold  the  appliance  in  place  (Fig. 
395).  The  sole  of  the  foot  including 
the  toes  is  made  of  rubber  with  a 
spring  mattress  (Fig.  391).  Com- 
fortable bearings  are  provided  by 
proper  fittings  and  suitable  linings. 
The  pressure  needed  to  secure  firm- 
ness is  distributed  over  the  entire  leg 
from  the  ankle  to  the  knee.     With  this  appliance  the  wearer  can 

rise  on  the  ball  of  the  foot  without 
subjecting  to  pressure  the  face  of 
the  stump  or  straining  the  ankle 
joint.  If  there  be  a  tendency  to 
retraction  of  the  heel,  the  leather 
sheath  at  the  back  is  reinforced 
with  metal,  shaped  to  hold  the  heel 
down  and  obviate  the  deformity. 
With  this  appliance  in  place  the 
wearer  walks,  striking  the  heel 
first,  then  rolling  on  the  sole  until 
the  ball  is  reached,  and  then  ris- 
ing on  the  ball  and  receiving  as- 
sistance in  walking.  Fig.  396 
shows  the  appliance  in  place  with 
the  shoe  on  and  the  wearer  walk- 
ing with  the  weight  on  the  ball  of 
the  foot,  similar  to  the  position 
taken  by  the  natural  foot  when 
in  the   act  of  throwing  the  body 

396. — Appliance   for   Instep  °  d 

Amputation  in  Use.  forward. 


A.  A.  MARKS,  N.  Y. 


Fig. 


618 


ARTIFICIAL   LIMBS 


RETRACTED    HEELS 


Fig.  397.  —  Appliance  for 
Retracted  Heel  follow- 
ing Tarsal  Amputation. 


Retracted  heels  occur  as  sequels  to  tarsal  amputations  which 
remove  the  insertion  of  the  muscles  op- 
posed to  the  muscles  of  the  calf.  In 
passing,  it  might  be  proper  to  state  that 
an  amputation  through  the  ankle  joint 
or  immediately  above  it  is  to  be  pre- 
ferred to  those  which  do  not  leave  re- 
maining the  insertion  of  the  anterior 
tibial  muscles. 

The  apparatus  just  described  will 
not  meet  the  indications  presented  by 
"  retracted  heels."  Pressure  on  the 
face  of  the  stump  is  not  tolerated,  and 
the  weight  must  be  borne  immediately 
below  the  knee  or  about  the  thigh.  For 
the  purpose  the  appliance  shown  in  Fig. 
397  will  be  found  serviceable  in  a  cer- 
tain number  of  cases.  The  rear  half  is  made  of  metal,  the  front 
of  leather,  capable  of 
being  laced.  This  permits 
of  close  fittings  about  the 
heel  and  tends  to  force  it 
back  to  its  proper  position. 
If  the  sides  of  the  leg  are 
sloping,  the  fitting  can  be 
such  as  to  apply  all  the 
weight  on  the  leg  imme- 
diately below  the  knee. 
!Fig.  398  shows  the  appa- 
ratus applied  with  the 
patient  sitting.  Disuse, 
atrophy  of  the  muscles  of 
the  leg,  make  the  applica- 
tion of  this  appliance  of 
doubtful  utility  after  a 
certain  period  of  time  fol- 
lowing the  amputation. 


Fig.    398. — Appliance  for   Retracted   Heel 
following  Tarsal,  Amputation  in  Place. 


ANKLE-JOINT   AMPUTATIONS 


619 


Fig.  399. — Appliance  with  An- 
nular Top  for  Retracted  Heel 
following  Tarsal  Amputation. 


When  this  appliance  is  not  found  to  meet  the  indications,  it 
becomes  necessary  to  fit  the  patient  with  an  apparatus  having  an 
annular  top  or  possibly  a  knee-joint 
and  thigh  support.  The  annular  top 
can  be  applied  to  a  leg  constructed 
as  described.  An  appliance  of  this 
sort  is  shown  in  Fig.  399.  Knee- 
joints  and  thigh  supporters  can  be 
applied  to  either  kinds  of  artificial 
legs.  Fig.  400  shows  an  apparatus 
with  knee-joint  and  thigh  supporter. 
When  the  annular  top  is  employed 
the  support  is  calculated  to  be  lo- 
calized immediately  below  the  knee. 
When  the  knee-joint  and  thigh  sup- 
port are  required  as  shown  in  the 
illustration  the  lower  section  is 
made  of  aluminium,  with  the  rear 

sheath  of  leather.     The  thigh  support  incases  the  thigh  and  holds 

it    sufficiently    firm    to    obviate 
slipping  of  the  leg  in  the  socket. 

ANKLE-JOINT   AMPUTATIONS 

Ankle-joint  amputations,  or 
so-called  tibio-tarsal  amputa- 
tions (Syme  of  Pirogoff),  with 
the  malleoli  removed  and  the 
heel  flap  utilized  over  the  face 
of  the  stump,  present  conditions 
exceedingly  favorable  to  the 
application  of  artificial  appa- 
ratus. If  the  scar  be  across 
the  face  of  the  stump,  they  be- 
come non-end-bearing  stumps ; 
per  contra,  if  the  scar  be  placed 
anteriorly  they  are  end-bearing 

Fig.  400,-Appliance  with  Knee  Joint         blimps,    which    latter    condition 
and  Thigh  for  Tarsal  Amputations.  is,    of    COUl'Se,    the    most    f  aVOl'- 


620 


ARTIFICIAL    LIMBS 


able  one  for  prothesis.     Fig.  401  shows  an  appliance  suitable  to 
cases  with  end-bearing  stumps.     The  construction  of  this  appli- 


ance is  very  simple.      The  front, 


Fig.  401. 


-Appliance  for  Ankle-joint 
Amputations. 


which  is  the  resisting  part,  and 
the  core  of  the  foot,  are  cast  in 
aluminium,  the  interior  surface 
being  formed  to  receive  the  an- 
terior surface  of  the  leg  from 


the  knee  down.  It  is  so  fitted 
that  pressure  will  be  distributed 
over  the  front  area,  the  shin- 
bone  and  the  soft  parts  of  the 
leg  being  protected  and  not  al- 
lowed to  bear  pressure.  The 
rear  part  is  of  leather,  shaped 
to  fit  the  calf  and  back  of  the 
leg.  It  is  attached  at  its  lower 
end  to  the  aluminium  socket 
and  when  the  stump  is  in  place, 

it  incases  the  whole  apparatus  from  the  knee  down,  holding  the 

leg  in  place  with  firmness,  the  pressure  being  regulated  by  the 

lacing.    The  foot  is  of  sponge 

rubber,    reinforced   with   the 

spring   mattress    (Figs.    390 

and  391).     Weight  is  taken 

by  the  end  of  the  stump  rest- 
ing on   a  surface  of  proper 

shape,  covered  by  a  suitable 

pad.      The    strain    resulting 

from  rising  on  the  ball  of  the 

foot  is  not  permitted  to  come 

on  the  stump,  being  distrib- 
uted over  the  leg,  about  the 

sides  of  the  shin  from  knee 

to    ankle.      A    stocking    and 

shoe  are  drawn  over  the  foot. 

Fig.  402  shows  the  appliance 

in   place   as   stated.      If  the 

end   of  the   stump   is   tender     *,       ino       .  . 

i  .biG.    402.—  Appliance    for    Ankle-joint 

because     of     sensitive      nerve  Amputations  in  Place. 


LEG   AMPUTATIONS 


621 


endings,  or  because  the 
scar  crosses  the  face  of  the 
stmnp,  an  appliance  which 
is  supported  by  an  annular 
arrangement  of  the  upper 
portion  may  be  used,  though 
this  will  probably  have  to 
be  supplemented  by  a  thigh 
support.  Fig.  403  shows 
the  annular  arrangement 
spoken  of,  which  is  intended 
to  support  the  pressure  be- 
low the  knee,  but  is  also 
fitted  with  a  thigh  sup- 
porter. 

LEG   AMPUTATIONS 


Fig.  404.  —  Appli- 
ance foe  Taper- 
ing Tibial  Stump. 


Fig.  403. — Appliance 
ron  End-bearing 
Stumps  at  Ankle 
Joint. 


Leg  amputations  may 
usually  be  fitted  with  arti- 
ficial appliances  similar  to  those  described  in 
connection  with  amputations  at  the  ankle 
joint.  However,  it  is  desirable  to  apply  an 
apparatus  which  does  not  require  lacing  at  the  leg  itself,  and  this 
is  only  possible  if  the  stump  ta- 
pers toward  the  end.  If  the  dis- 
tal portion  of  the  remaining 
stump  is  wider  than  any  portion 
higher  up,  as  obtains  when  the 
bone  section  is  made  below  the 
junction  of  the  middle  and  lower 
thirds  of  the  tibia,  it  will  be 
necessary  to  use  artificial  appli- 
ances similar  to  those  described 
under  ankle-joint  amputations. 
Tapering   stumps   must   be 

fitted   with   appliances   that  give 

„  „    i  „  <•         ,i  ,  ■■  Fig.   405 — Appliance    for    Tapeki.no 

ample    room    tor   the    extremity.  „  0 

1  J  Tibial   Stumps,    Showing    JJegpee 

That   is,   the   ends   are   Suspended  of  Knee  Flexion  Obtainable. 


622 


ARTIFICIAL   LIMBS 


in  space.  As  they  taper  towards  the 
ends,  they  may  be  inserted  from  the 
tops  of  the  sockets,  in  contradistinction 
to  those  just  discussed.  The  socket  is 
hollowed  out  near  the  bottom  and  an 
abundance  of  room  provided,  allowing 
of  free  circulation  of  air.  The  leg 
socket  and  foot  core  are  made  of  a  single 
piece  of  wood.  The  rubber  foot  is  con- 
structed as  already  shown  (Figs.  390 
and  391).  Figs.  404  and  405  show  sec- 
tional views  of  an  appliance  for  the  pur- 
pose. 

Short  tibial  stumps  which  are  two  or 


Fig.      406.  —  Appliance      for 
Short  Tibial  Stumps. 

more  inches  in  length,  with  the  knee 
articulation  capable  of  a  range  of  mo- 
tion through  90  degrees  or  more,  may 
be  advantageously  fitted  with  an  ap- 
pliance shown  in  Figs.  406  and  407. 
Fig.  407  shows  the  appliance  with  the 
patient  standing,  the  action  of  the  knee 
joint  being  clearly  presented. 

This  appliance  is  constructed  as 
follows :  The  socket  which  receives  the 
stump  is  excavated  to  accommodate 
the  stump.  Sufficient  space  is  allowed 
for  in  the  socket  to  allow  of  circula- 
tion of  air,  and  the  stump  is  permitted 
to  hang  freely  in  space.  The  appli- 
ance  is    made    of   basswood    strongly 


Fig.  407. — Appliance  for  Short 
Tibial  Stumps  in  Place. 
(Posterior  View.) 


LEG    AMPUTATIONS 


623 


Fig.  408. — Mechanism  of  Knee 
Joint  for  Short  Tibial 
Stumps. 


A.  A-  MARKS,  N   Y 


Fig.  409. — Knee  Joint  in  Place,  Sho\vin< 
Degree  of  Flexion. 


banded  together  with  rawhide.     Knee  joints  are  of  the  ginglymoid 

pattern.     The  thigh-piece  is  made  of  leather.     Fig.  408  shows  the 

upper  section  of  the  leg  and  the  lower  section  of  the  thigh-piece, 

with  the  knee  joints  disconnected 

at     their     articulations ;     aa     are 

screws  which  hold  the  bolts  bb  in 

place;  cc  are  the  bushings  which 

work  on  the  bolts  and  receive  the 

wear ;  a  lacing  is  used  to  regulate 

the  action  of  the  knee.     Fig.  409 

shows  the  apparatus  in  place  with 

the  knee  bent. 

KNEE-BEARING   STUMPS 

Knee-bearing  stumps  are  fitted 
with  appliances  similar  to  those 
just  described.  A  bolt  joint  fitted 
with  a  spring  forms  the  axis  of 
the  knee.     It  is  flanged  on  one  end      _ 

°  riG.    410. — Mechanism    of    Appli- 

and  threaded  011  the  Other.      When  ance  in  Knee-bearing  Stumps. 


624 


ARTIFICIAL    LIMBS 


Fig.    411. : —  Appliance    for 
kxee-bearixg    stumps. 


the  bolt  is  passing  through  the  metal  ear 
which  is  riveted  to  the  lower  leg,  the  head 
sinks  into  its  bed  and  the  threaded  end 
screws  into  the  ear  riveted  to  the  oppo- 
site side.  Fig.  410  shows  the  mechanism 
of  the  apparatus ;  a  is  the  bolt.  The  set 
screw  ~b,  placed  into  the  flanged  end,  pre- 
vents the  bolt  from  moving  and  working 
out;  c  is  the  check  cord  screw;  d  the 
check  cord;  g  the  spring  piston;  h  the 
spiral  spring;  i  the  cylinder.  The  rela- 
tions and  functions  of  these  parts  can  be 
understood  by  an  examination  of  Figs. 
411  and  412. 

The  action  of  the  spring  holds  the  leg 
at  flexion  when  the  wearer  is  seated,  and 
urges  the  leg  forward  when  walking. 
The  range  of  articulation  can  be  regu- 
lated by  means  of  a  pad  placed  between 
the  lower  end  of  the  check  cord  and  the 
bridge  under  which  it  passes.  These 
pads  can  be  reached  through  the  opening 
in  the  calf  of  the  leg.     The  upper  loops 


of  the  check  cords  rest  in 
their  respective  channels 
and  through  them  a  steel 
screw  is  passed  and  set. 
The  center  of  motion, 
being  placed  below  the 
natural  knee,  causes  a 
disparity  in  length  in  the 
two  thighs.  This  is  a 
minor  consideration 
when  balanced  against 
the  utility  of  the  mech- 
anism. 

Disarticulated   knee 
stumps    are    fitted    with 


Fig.  412. — Appliance  for  Knee-bearixg  Stump, 
Showing  Degree  of  Flexion  Obtaixable. 


LEG   AMPUTATIONS 


625 


practically  the  same  appliances  described  under  "  knee-bearing 
stumps."  It  may  be  said  that  disarticulations  at  the  knee  joint 
bear  pressure  very  well  and  present  a  condition  of  affairs  quite 
favorable  to  prothesis. 


THIGH   STUMPS 

Thigh  stumps  are  fitted  with  much  the  same  appliances  as  are 
applied  to  knee-bearing  stumps.     The  application  of  an  artificial 

limb  should  not  be  post- 
poned   beyond    what    is 

necessary  to  obtain  a 

tolerant  stump.     Persons 

who  carry  an  idle  thigh 

stump  for  a  considerable 

period    of    time    usually 

have  a  certain  degree  of 

contracture  of  the  flexor 

muscles  (the  psoas,  etc.) 

which  inclines  the  stump 

forward,    and   this    must 

be  overcome  before  a 

comfortable    appliance 

can     be     advantageously 

worn.      As   a  rule  thigh 

stumps     will     not     bear 

pressure    on    their    ends. 

Fig.  413  shows  the  usual 

form    of    artificial    limb 

applied  to  thigh  stumps ; 

Fig.    414    shows    a    rear 

view  of  the  same.  A  rub- 
ber foot  as  already  de- 
scribed is  attached  at  the 

ankle,  and  the  leg  por- 
tion   is    hollowed    out    to 

415  shows  the  parts  of  the  knee  mechanism. 
A  is  the  T-joint  which  is  secured  to  the  knee-block  located  at  the 
lower  end  of  the  stump  socket.  The  two  arms  work  in  journals 
made  in  the  leg  section;  bb  are  the  cap  screws  that  hold  the  T-joint 


Fig.  413.  —  Appliance 
for  Thigh  Stump. 
(Lateral    View.) 

decrease  weight.    Fij 


Fig.  414. — Appli- 
ance for  Thigh 
Stump.  (Pos- 
terior   View.) 


626 


ARTIFICIAL  LIMBS 


c 

b     b 

c 

r 

1     f 

3 

H> 

® 

® 

ill 

iiiiiii 

Fig.   415. — Mechanism  of   Kxee    Joint  in  Ap- 
pliance for  Thigh  Stump. 


to  its  place;  cc  the  caps; 
d  the  spring  piston ;  e  the 
spiral  spring;  /  the  cyl- 
inder cover,  and  parts 
of  the  spring  together ; 
Hi  represent  the  steel 
screws  used  to  hold  the 
T- joint  firmly  to  the 
thigh.  The  joint  a  has  the 
shape  of  an  inverted  T, 
hence  its  name,  T-joint. 
When  the  leg  and  thigh 
sections  are  placed  to- 
gether, the  arms  of  the 
T-joint  rest  in  boxes  and 
are  held  by  two  hard- 
wood caps,  cc,  which  are 
secured   by  long  screws, 

bb,  which  depend  for  their  security  on  steel  nuts,  imbedded  in  the 

front  part  of  the  leg.     The  pressure  of  the  caps 

on  the  joints  can  be  regulated  by  the  screws; 

thus  any  desired  tension  on  the  articulation  can 

be  made.     The  steel  lever  with  ball  on  the  end, 

projecting  from  the  back  of  the  joint,  operates 

in  the  cavity  of  the  hardwood  piston  d;  the  pis- 
ton is  inserted  in  one  end  of  the  steel  spring,  e, 

which  has  its  lower  part  incased  with  leather, 

and  then  placed  in  a  metal  cylinder  /.     The 

lower  convex  end  of  the  cylinder  is  received  on 

a  bridge  placed  in  the  interior  of  the  leg  in  the 

region  of  the  calf.     The  operation  of  the  spring 

is  twofold ;   it  urges  the  lower  leg  forward  in 

walking,  and  holds  it  at  full  flexion  when  sit- 
ting.    This  is  done  in  the  following  manner: 

When  the  leg  is  extended,  the  point  at  which 

the  spring  pressure  is  applied  is  on  the  end  of 

a  steel  lever  projecting  an  inch  back  of  the  cen-     Fig.     416.  —  Appli- 

ter  of  motion  in  the  knee.     This  urffes  further  ^NCE    ° 

o  Stump.     Knee  in 

extension    (Fig.   416),  the  lever  revolves  with  Full  Extension. 


Fig.  417. — Appliance  for  Thigh 
Stump.  Knee  in  Partial 
Flexion. 


Fig.    418.  —  Appliance  for   Thigh 
Stump.     Knee  in  Full  Flexion. 


Fig.  419.  —  Appliance 
for  Hip  Amputa- 
tion. (Anterior 
View.) 

42 


Fig.  420. — Appliance 
for  Hip  Amputa- 
tion. (Posterior 
View.) 


Fig.  421. — Ap- 
pliance FOR 
Hip  Amputa- 
tion. (Lat- 
eral View.) 


627 


628 


ARTIFICIAL   LIMBS 


Fig.     422.  —  Appliance     for     Hip 
Amputation.    (Patient  Sitting.) 


the  joint,  and  when  the  leg  is 
partly  flexed  (Fig.  417),  it  has 
been  carried  to  a  neutral  point 
where  the  spring  neither  urges 
flexion  nor  extension ,  but  when 
the  knee  is  farther  flexed  (Fig. 
418),  the  lever  has  passed  for- 
ward of  the  neutral  line  and  the 
spring  forces  the  ball  upward, 
urging  farther  flexion,  and  when 
the  flexion  is  at  its  limit,  the  leg 
is  kept  in  that  position  by  the 
spring.  Thus,  the  objection  to 
the  usual  spring  knee  articula- 
tion is  removed,  that  of  the  ten- 
dency of  the  leg  to  fly  out  when 
the  wearer  is  sitting  and  un- 
guarded. 


HIP-JOINT   AMPUTATIONS 

Hip-joint  amputations  require  conditions  of  ap- 
paratus quite  similar  to  that  just  described,  except 
that  suspension  is  more  complex.  For  the  purpose 
an  appliance  such  as  is  shown  in  Fig.  419  is  ser- 
viceable. The  waist  belt  and  suspenders  hold  the 
limb  in  apposition  to  the  pelvis.  Figs.  420,  421, 
and  422  show  the  appliance  in  place.  The  latter 
shows  the  conditions  when  the  patient  is  seated. 


AMPUTATIONS   OF   UPPER   EXTREMITIES 

Artificial  appliances  following  amputations  at 
the  upper  extremities  do  not,  of  couse,  involve  quite 
the  same  problem  as  obtains  with  those  of  the  lower 
extremity.  Cosmetic  effect  plays  an  important 
part  in  this  connection,  and  this  is  readily  con- 
served by  mechanical  means.  Amputation  of  the 
hand  lessens  greatly  the  utility  of  the  limb.  How- 
ever, if  the  forearm  is  intact,  an  artificial  appli- 


Fig.  423.— Ap- 
pliance FOR 
Amputation 
of  Hand. 


AMPUTATIONS    OF   UPPER   EXTREMITIES 


629 


ance  such  as  is  shown  in  the  illustration  (Fig.  423 )  will  be  found 
of  service.  Amputations  through  the  forearm  are  fitted  with 
much  the  same  style  of  apparatus. 

Amputations  above  the  elbow  joint  are  fitted  with  an  appliance 
which  is  fitted  with  a 
spring  permitting  of 
flexion  of  the  elbow. 
Fig.  424  shows  an 
apparatus  of  this 
sort.  Disarticulation 
at  the  shoulder  joint 
is  also  followed  by 
the  application  of 
apparatus  which  con- 
serves cosmetic  ef- 
fect, but,  of  course, 
utility  is  not  achieved 
by  this  means,  except 

by  the  exercise  of  a  complicated  mechanism  which  is  of  necessity 
operated  for  a  given  purpose  by  the  opposite  hand. 

The  greatest  achievement  in  the  part  of  artificial  appliances 
following  amputations  is  the  aid  given  the  afflicted  in  locomotion. 
In  addition  to  this,  the  usefulness  of  certain  kinds  of  stumps  in 
various  portions  of  the  limbs  as  applied  to  subsequent  prothesis 
has  been  developed  to  no  small  degree,  as  the  outcome  of  the  arti- 
san's labor.  It  is  to  be  regretted  that  more  attention  has  not  been 
paid  to  this  portion  of  the  problem  in  teaching  operative  surgery. 
The  general  surgical  rule  that  every  inch  of  limb  should  be  saved 
is  not  uniformly  wise.  A  perusal  of  the  discussion  offered  above 
may  lead  to  some  valuable  conclusions  in  this  connection.  The 
problem  of  what  occupation  the  afflicted  person  is  to  follow  should 
enter  into  the  question  and,  if  this.be  borne  in  mind,  no  doubt  re- 
amputation  will  become  less  frequently  necessary. 


Fig.  424. — Appliance  for  Amputation'  of  Arm. 


CHAPTEE    XXXIV 
MISCELLANEOUS   OPERATIONS 

Fracture  of  the  patella — Union  of  fractured  bones — Xailing  the  neck  of  the 
femur — Skin-grafting. 

FRACTURE   OF   PATELLA 

Fracture  of  the  patella  when  treated  by  operative  measures 
of  relief  presents  a  problem  in  which  the  question  of  infection 
plays  a  more  important  part  than  obtains  in  other  portions  of  the 
body,  when  the  condition  for  which  relief  is  attempted  is  bal- 
anced against  the  dire  results  of  the  infection.  For  some  un- 
known reason  the  knee  joint  is  peculiarly  susceptible  to  infection, 
and  also  for  an  unknown  reason  its  occurrence  results  fatally  at 
times,  and  often  in  complete  loss  of  function  of  the  joint.  For 
this  reason  especial  precautions  should  be  taken  against  the  intro- 
duction into  the  wound  of  infectious  substances,  and,  whatever 
may  be  said  of  the  question  of  wearing  gloves  when  the  surgeon 
operates  in  other  portions  of  the  body,  they  should  be  worn  by  the 
operator  and  his  assistants  when  the  knee  joint  is  invaded. 

The  technic  of  the  operation  does  not  call  for  special  adroit- 
ness nor  the  exercise  of  finesse  in  manipulation,  and  the  gloves 
need  not  be  regarded  as  hampering  the  operator  in  the  least. 
Again,  the  operation  does  not  call  for  the  exercise  of  prolonged 
physical  exertion,  and  the  temperature  of  the  operating  room  need 
not  be  high,  consequently  the  surgeon  is  not  caused  to  perspire 
freely,  as  obtains  during  operations  of  greater  magnitude,  and  the 
objection  to  the  use  of  gloves  on  the  score  that  accidental  perfora- 
tion might  liberate  into  the  field  sweat  infested  with  bacteria 
from  the  skin  of  the  operator's  hands  need  not  be  taken  into  ac- 
count. 

In  other  respects,  the  field  of  operation  is  prepared  in  a  man- 
ner similar  to  that  employed  in  other  portions  of  the  body.    When 

630 


FRACTURE    OF    PATELLA  631 

the  region  of  the  knee  has  been  injured  by  the  force  causing  the 
fracture,  healing  of  the  trauma  should  be  complete  before  the 
operation  is  undertaken,  or,  if  this  be  regarded  as  an  objectionable 
delay,  the  solution  of  continuity  in  the  skin  should  be  sterilized 
with  pure  carbolic  acid  and  alcohol  immediately  before  section 
of  the  skin  is  made.  After  the  apposition  of  the  fragments  is  com- 
pleted, the  superficial  wound  is. closed  with  silk-worm  gut.  The 
joint  is  not  drained  as  a  rule.  In  some  instances  a  small  drain  is 
carried  through  the  skin  from  the  dependent  portion  of  the  joint, 
i.e.,  at  its  external  aspect.  However,  the  use  of  drainage  in  this 
class  of  cases  is  objectionable  and  may  constitute  an  avenue  of  en- 
trance of  infection.  If  drainage  is  employed,  horsehair  or  silk- 
worm gut  are  the  most  useful  and  least  objectionable  agents  for  the 
purpose.  After  the  skin  wound  is  closed  the  usual  protective  dress- 
ing is  applied,  though  in  this  situation  it  is  well  to  be  somewhat 
lavish  in  the  use  of  gauze,  in  order  to  permit  of  an  equable  appli- 
cation of  the  immobilizing  apparatus. 

The  limb  may  now  be  placed  on  a  posterior  splint.  It  will 
be  found,  however,  that  plaster-of-Paris  is  the  best  dressing  to 
use  for  the  purpose.  The  patient  is  placed  in  bed  with  the  thigh 
flexed  upon  the  pelvis  and  the  leg  supported  by  pillows.  The 
quadriceps  extensor  is  thus  relaxed  and  strain  upon  the  approxi- 
mation sutures  which  hold  the  fragments  in  apposition  is  avoided. 
If  drainage  has  been  employed,  a  window  is  cut  into  the  plaster 
cast  on  the  third  day  following  the  operation,  which  corresponds 
in  size  and  location  to  the  site  of  egress  of  the  drain,  which  is 
located  some  distance  from  the  wound  of  approach  to  the  site  of 
fracture,  thus  minimizing  the  danger  of  the  introduction  of  in- 
fection at  this  time.  The  drainage  wound  is  redressed  at  once. 
On  the  tenth  day  after  the  operation  the  cast  is  cut  clown,  the 
stitches  removed  from  the  skin,  and,  after  cleansing,  under  aseptic 
precautions,  the  entire  knee  and  contiguous  parts  the  cast  is  re- 
applied to  the  limb  and  held  in  place  by  encircling  strips  of  ad- 
hesive plaster.  The  posture  of  the  limb  as  previously  employed  is 
reassumed.  At  the  end  of  another  three  days  the  wound  is  again 
dressed.  At  this  time  the  attendant  grasps  the  patella  between 
the  thumbs  and  forefingers  of  both  hands,  holding  firmly  the  frag- 
ments in  position  (Fig.  425),  and  moves  it  carefully  from  side  to 
side.     The  object  of  this  manipulation  is  to  avoid  adherence  of 


632 


MISCELLANEOUS    OPERATIONS 


the  posterior  surface  of  the  patella  to  the  condyles  of  the  femur. 
If  this  can  be  avoided,  the  subsequent  manipulations  destined  to 
restore  motility  in  the  joint   are  less  liable  to  cause  refracture. 


'            ** 

' 

*■ 

**  S" 

^^ 

tk     -i """.  '•£&*  d 

JsBHI 

,   M. 

^v 

I .  / 

J 

Fig.  425. 


-Lateral  Manipulation  of  Patella  to  Obviate  Adherence  to  Con- 
dyles of  Femur. 


Xormally  the  patella  glides  on  the  smooth  surfaces  of  the  con- 
dyles, and  if  it  becomes  adherent,  it  is  easy  to  see  how  an  effort 
to  flex  the  leg  would  cause  the  line  of  union  to  give  way. 

The  limb  is  now  immobilized  in  a  new  plaster  cast,  in  which 
it  is  allowed  to  remain  for  three  weks.  At  this  time  the  cast  is 
cut  down,  the  patella  moved  again  laterally  as  described,  and  the 
cast  fastened  back  in  place.  Complete  immobilization  is  now  no 
longer  necessary.  Each  day  the  cast  is  removed  and  lateral  ma- 
nipulation of  the  patella  practiced,  but  at  this  time  flexion  of 
the  limb,  either  passively  or  actively,  is  to  be  avoided.  The  latter 
is  to  be  avoided  until  seven  weeks  after  the  operation,  and  at  first 
the  patella  should  be  steadied  as  the  leg  is  cautiously  and  carefully 
bent.  As  a  rule,  no  attempt  to  obtain  complete  flexion  of  the 
joint  should  be  attempted  until  after  the  expiration  of  twelve 
weeks  after  the  operation.     In  the  meantime  the  limb  should  be 


UNION    OF   FRACTURED    BONES 


633 


massaged  daily.  If  infection  of  the  joint  occurs,  the  cast  must 
be  cut  down,  the  wound  completely  opened,  drainage  established 
and  the  joint  treated  as  infected  joints  are  taken  care  of  from 
other  causes. 

UNION   OF   FRACTURED   BONES 

The  union  of  fractured  bones  by  holding  in  apposition  the 
fragments  by  means  of  wire,  nails,  pegs  or  similar  device  is  fol- 
lowed by  drainage  in  most  instances.  The  use  of  the  drainage  is 
governed  by  much  the  same  rules  which  are  applicable  to  wounds 
generally,  except,  perhaps,  that  in  this  class  of  cases  the  oozing 
of  blood  from  the  traumatized  bone  may  be  regarded  as  a  special 
indication  for  its  use.     After  the  protective  dressing  is  applied, 


Fig.  426. — ParkhiU's  Screws  in  situ.     (Bryant.) 


the  bone  and  contiguous  joints  are  immobilized  in  plaster-of- 
Paris,  and  on  the  third  day  following  the  operation  the  drain  is 
removed  through  a  small  window  cut  into  the  cast  for  the  pur- 
pose. On  the  tenth  day  after  the  operation  the  window  in  the 
cast  is  enlarged  and  the  sutures  removed  from  the  wound.  The 
wound  is  then  dressed,  and  in  most  instances  need  not  be  dis- 
turbed until  the  cast  is  cut  down  for  some  other  purpose.  If 
there  be  a  superficial  infection,  the  dressing  is  changed  every  two 
days  until  healing  takes  place.  In  instances  where  long  bones, 
such  as  the  tibia  cannot  be  held  in  proper  apposition,  a  devise 
employed   by   ParTchill   is   frequently   introduced    into   the   frag- 


634  MISCELLANEOUS    OPERATIONS 

ments.  When  the  device  is  in  situ  it  presents  the  conditions 
shown  in  Fig.  426.  This  method  of  treatment  renders  the  appli- 
cation of  a  plaster  cast  a  trifle  more  complicated,  as  the  instru- 
ment protrudes  through  the  plaster  cast  and  constitutes  an  avenue 
of  entrance  of  infection.  This  may  be  obviated  by  covering  the 
device  with  an  additional  dressing  independently  of  the  cast.  The 
latter  precaution  must  not  be  neglected.  The  wires  and  pegs  are 
not  always  well  borne  and  at  times  cause  irritation  and  must  be 
removed.  The  appearance  of  redness,  pain  and  swelling  at  the 
site  of  the  operation,  several  weeks  after  the  repair  has  been 
made,  suggests  that  the  foreign  substance  is  causing  trouble  and 
should  be  removed.  INTails  are  usually  left  protruding  from  the 
soft  parts,  and  should  be  removed  five  weeks  after  the  operation. 
ParTehill's  device  should  be  removed  at  the  expiration  of  the  same 
period  of  time. 

The  principle  of  treatment  in  these  cases  is  quite  similar  to 
that  applicable  to  fractures  generally.  The  wound  may  be  re- 
garded as  wounds  are  in  a  general  way,  except,  perhaps,  for  the 
variations  from  the  rule  mentioned  above.  In  a  certain  number 
of  cases  a  superficial  necrosis  of  bone  corresponding  in  extent  to 
the  perforations  made  by  the  retaining  apparatus  occurs,  a  small 
abscess  forms  and  a  sinus  persists  for  some  time  after  the  opera- 
tion. This  need  not  be  regarded  as  a  serious  complication,  nor 
indicative  of  failure  of  the  measure  of  relief.  It  means,  however, 
that  the  wound  needs  to  be  cleansed  at  intervals  of  two  days 
through  the  window  in  the  plaster  cast,  and  may,  indeed,  demand 
somewhat  protracted  attention  after  the  case  has  recovered  in  all 
other  respects.  An  application  of  tincture  of  iodin  to  the  sinus 
at  intervals  of  four  or  six  days  will  at  times  stimulate  granulation 
and  destroy  mild  infection. 

NAILING   THE    NECK   OF   THE   FEMUR 

bailing  the  neck  of  the  femur  for  fracture  is  practiced  in  a 
certain  number  of  cases  where  immobilization  by  mechanical 
means  is  contraindicated,  because  of  the  age  of  the  patient,  or  be- 
cause of  the  coexistence  of  some  complications  proclnding  the  em- 
ployment of  the  more  usual  methods  of  treatment. 

As  a  rule,  the  fixation  of  the  fragments  by  nailing  is  followed 


NAILING   THE   NECK   OF  THE   FEMUR  635 

by  the  application  of  a  plaster-of-Paris  cast  which  consists  of  a 
hip  spica  extending  down  to  but  not  including  the  knee  joint. 
The  wound  which  permits  of  the  introduction  of  the  nail  does 
not  require  drainage,  and  the  hip  joint  may  be  immobilized  and 
the  dressing  left  undisturbed  for  two  weeks  following  the  opera- 
tion. In  a  small  number  of  cases  it  may  be  necessary  to  cut  a 
window  into  the  cast  corresponding  to  the  point  of  insertion  of 
the  nail  in  order  to  cleanse  the  area.  However,  this  will  only 
rarely  be  necessary. 

The  patient  is  permitted  to  leave  the  bed,  and  is  encouraged 
to  go  about  on  crutches  after  the  third  day  following  the  opera- 
tion. The  cast,  as  already  stated,  is  removed  at  the  end  of  two 
weeks  following  the  operation,  and  the  nail  may  be  relied  upon 
to  hold  the  fragments  in  apposition  after  this.  The  hip  joint  may 
be  lightly  dressed  with  sterile  gauze  held  in  place  with  a  roller 
bandage.  The  nail  is  removed  at  the  end  of  six  weeks  following 
the  operation.  The  nail  is  left  protruding  from  the  skin  at  the 
time  of  the  operation,  and,  for  the  purpose  of  removal,  it  is  firmly 
grasped  by  a  strong  forceps  and  slowly  twisted  until  it  becomes 
loosened  when  it  is  readily  removed  with  slight  traction.  As  a 
rule,  a  slight  degree  of  necrosis  corresponding  to  the  seat  of  the 
nail  causes  it  to  be  quite  loose  at  the  end  of  the  six  weeks  men- 
tioned. If  the  nail  be  firmly  fixed  and  do  not  permit  of  easy  re- 
moval, it  may  be  grasped  near  its  head  by  a  strong  hysterectomy 
clamp  and  this  given  a  sharp  blow  in  the  direction  away  from  the 
limb  with  an  ordinary  mallet,  such  as  is  used  for  gouging  bone. 

In  most  cases  the  wound  heals  immediately  after  the  nail  is 
removed.  In  a  few  cases,  however,  a  sinus  persists  for  several 
weeks  after  the  nail  has  been  withdrawn.  This,  as  mentioned  in 
connection  with  the  wiring  of  fractures,  need  not  give  rise  to  any 
alarm,  and  the  sinus  actually  heals  in  a  short  time.  Infection 
should  not  occur  in  these  cases.  If  it  happens,  however,  the  nail 
must  be  at  once  removed,  and  drainage  established. 

A  certain  degree  of  motility  of  the  joint  occurs  at  the  end 
of  the  two  weeks  of  treatment,  and  this  will  be  found  to  be  suffi- 
cient to  obviate  complete  ankylosis.  However,  the  motion  in  the 
joint  will  be  found  much  impaired  after  healing  is  achieved. 
At  the  end  of  the  six  weeks,  the  joint  is  subjected  t<>  passive  motion 
and   massage   as    employed    following   fractures    in   general.      It 


636  MISCELLANEOUS    OPERATIONS 

is  not  wise  to  employ  very  largely  measures  destined  to  obviate 
ankylosis  until  after  union  has  taken  place.  Indeed,  the  nail, 
while  meeting  the  indications  when  treated  with  care,  will  not  be 
found  to  hold  the  fragments  in  place  when  the  joint  is  subjected 
to  passive  motion  too  early  in  the  postoperative  period.  It  is 
best  to  permit  the  patient  to  move  the  joint  only  as  much  as  is  the 
inevitable  outcome  of  going  about  in  the  ward  on  crutches.  As 
this  operation  is  usually  undertaken  on  patients  advanced  in  life, 
the  precautions  with  respect  to  hypostatic  pneumonia  and  bed 
sores  are  to  be  observed.  As  far  as  the  former  is  concerned,  the 
patient  must  be  caused  to  leave  the  bed  or  at  least  be  raised  to 
the  sitting  posture  as  soon  after  the  operation  as  is  possible.  The 
latter,  of  course,  is  a  question  of  frequent  change  of  posture  and 
attention  to  the  skin. 

SKIN-GRAFTING 

Skin-grafting  is  undertaken,  in  the  vast  majority  of  instances, 
for  the  relief  of  conditions  when  infection  to  a  greater  or  lesser 
degree  already  exists.  This  factor  in  the  problem  would  suggest 
the  employment  of  antiseptic  measures  throughout  the  care  of  the 
case.  However,  the  repair  of  the  wound  is  dependent  upon  the  vi- 
tality of  the  grafts,  and  as  this  is  more  or  less  impaired  as  the  result 
of  contact  with  antiseptic  solutions,  the  operative  technic  must 
be  carried  on  without  the  employment  of  these  agents. 

The  local  preparation  of  the  patient  may  be  carried  out  with 
antiseptics,  and,  indeed,  these  may  be  liberally  used  at  this  time. 
However,  immediately  before  the  operation  all  antiseptics  must 
be  removed  before  the  grafts  are  brought  in  contact  with  their 
new  residence.  For  the  purpose,  the  parts  are  cleansed  in  the 
usual  manner  and  ultimately  a  liberal  lavage  made  with  normal 
salt  solution.  During  the  operation,  normal  saline  solution 
should  be  used  as  a  cleansing  fluid.  The  salt  solution  is  regarded 
as  a  contributing  factor  to  the  maintenance  of  the  nutrition  of 
the  grafts. 

On  the  other  hand,  great  care  must  be  taken  to  avoid  accidental 
contamination  of  the  operative  field,  for,  while  the  use  of  salt  solu- 
tion may  contribute  to  the  vitality  of  the  grafts,  it  also  constitutes 
a  culture  medium  exceedingly  favorable  to  the  growth  of  bacteria, 


SKIN-GRAFTING 


637 


a  fact  borne  out  by  the  rather  virulent  character  infection  takes 
on  when  developed  under  the  conditions  presented. 

One  of  the  most  prolific  causes  of  failure  in  achieving  a  favor- 
able ultimate  outcome  in  these  cases  is  the  fact  that  the  protec- 
tive dressing  becomes  adherent  to  the  grafts,  and  when  it  is 
removed  the  grafts  are  torn  away.  This  applies  with  equal  force 
to  Thiersch,  Riverdian  or  other  grafts.  To  avoid  this,  the  pro- 
tective dressing  is  kept  constantly  moist  with  normal  salt  solution, 
the  theory  being  that  the  gauze  will  not  adhere  to  the  grafts  under 


Fig.  427. — Method  of  Preparing  Rubber  Tissue  for  Dressing  Wound  after 

Skin-grafting. 


these  conditions.  This  has  not  been  found  to  achieve  the  object, 
and  in  addition  the  moist  dressing  constitutes  a  condition  very 
favorable  to  the  entrance  of  infection. 

A  method  which  has  yielded  the  best  results  is  as  follows: 
After  the  wound  is  thoroughly  dried,  rubber  tissue  is  cut  to  a 
suitable  size,  and  this  is  fenestrated  at  intervals  of  a  square  inch 
by  first  folding  the  tissue  and  then  excising  diamond-shaped  por- 
tions in  the  manner  shown  in  Fig.  427.  When  the  entire  portion 
of  tissue  is  prepared,  it  presents  a  condition  shown  in  Fig.  428. 


638 


MISCELLANEOUS    OPERATIONS 


The  wound  is  now  covered  with  sterile  olive  oil  and,  after  the 
rubber  tissue  has  also  been  submerged  in  sterile  olive    oil,  it    is 


Fig.  428, 


-Rubber  Tissue  Prepafed  for  Application  to  Wound   after 
Skin-grafting. 


Fig.  429. — Fenestrated  Rubber  Tissue  Applied  to  Wound  after  Skin-grafting. 


applied  directly  to  the  wound.  Whatever  secretion  the  wound 
may  throw  off  finds  its  way  into  the  protective  dressings  through 
the  diamond-shaped  openings.     Fig.  429  shows  the  rubber  tissue 


SKIN-GRAFTING  639 

applied.  The  square  of  gauze  (Fig.  187)  applied  directly  con- 
tiguous to  the  rubber  tissue  is  also  saturated  with  the  sterile  oil, 
and  outside  of  this  the  usual  protective  dressing  is  applied. 

When  the  dressing  is  changed,  which  should  be  done  every 
forty-eight  hours  subsequent  to  the  operation,  the  rubber  tissue  is 
readily  removed  without  damage  to  the  grafts.  At  the  end  of 
the  third  dressing  the  collection  of  oil  adherent  to  the  wound  and 
contiguous  skin  may  be  removed  by  gently  swabbing  the  surface 
with  tincture  of  green  soap  applied  by  means  of  a  cotton  pledget 
and  the  resultant  lather  removed  by  liberal  lavage  with  sterile 
water  or  salt  solution. 

In  most  cases  sloughing  of  a  portion  of  the  grafts  takes  place. 
This  will  become  manifest  at  the  end  of  a  week  and  is  accompanied 
by  a  liberal  discharge  of  offensive  secretion.  By  this  time,  how- 
ever, the  healthy  grafts  will  have  become  sufficiently  adherent  to 
warrant  employment  of  a  mild  solution  of  carbolic  acid  (1  in  250) 
as  a  cleansing  solution.  The  carbolic  acid  solution  should,  how- 
ever, be  ultimately  displaced  with  sterile  water,  and  under  no  cir- 
cumstances should  a  wet  dressing  containing  an  antiseptic  be  per- 
mitted to  remain  in  contact  with  the  wound  before  the  total  num- 
ber of  grafts  have  become  adherent,  unless  the  wound  present 
evidence  of  infection. 


INDEX 


Abdomen,  drainage  of,  433 

operations  on,  422 

strapping  of,  476 
Abdominal   adhesions,  474 

■massage  for,  474 
Abdominal  belts,  475 
Abdominal  operations,  lung  complica- 
tions after,  4G1 

parotitis  after,  464 
Abdominal  supporters,  475 
Abdominal   supporting  corsets,   480 
Abdominal  wound,  closure  of,  435 

dressing  of,  436 

superficial  drainage  of,  436 
Abscess  of  liver,  509 
Absorbable  ligature  material,  86 
Acquired   obesity,  '31 
Acute   cardiac   dilatation   in   transfu- 
sion, 253 
Adamkiewicz's     formula     for     rectal 

feeding,  296 
Adhesions  following  celiotomy,  473 
Adrenalin   in  shock,  234 
Alcohol,  23 

abstinence  from,  25 

administration  of,  after  operations, 
28 
in  alcoholics,  27 
Alcoholics,  preparation  of,  23 
Alcoholism,  chronic,  24 

diet  in,  26 
Amputations,  606 

at  ankle,  619 

at  hip  joint,  628 

at  instep,  616 

drainage  after,  609 

of  leg,  021 

of  upper  extremities,  628 

open  treatment  of,  607 

retracted   heels   after,   618 


Ankle-joint   amputations,   619 
Antisepsis    in    cleansing    skin    in    in- 
fected cases,  51 
Antiseptic  powders,  217 

application  of,  220 
Antiseptic  solutions,  117 
Anus,  fistula  of,  550 

operations  on,  548 
Appendectomy,  496 
Appendicostomy,  498 
Arrangement  of  furniture  in  office,  8 

of  reception  room  and  office,  8 
Artificial  feet,  613 
Artificial  larynx,  Gliick's,  387 

Gussenbauer's,  386 
Artificial  limbs,  612 
Aspiration  after  thoracotomy,  401 
Assistants,  preparation  of,  124 
Attire  of  patients,  53 

of  non-sterile  nurse,  138 

of  sterile  nurse,  138 

of  surgeon,  137 


B 


Bacteria  in  gastrointestinal  canal,  425 

Balsam  of  Peru  gauze,  77 

Basin,  handling  of,  116 

Beard,  care  of,  43 

Bed  for  abdominal  cases,  39 
for  head  cases,  39 
for  shock,  229 

Bedside  table  for  postoperative  care, 
232 

Belts,  abdominal,  475 

Biliary  fistula,  517 

Biliary     passages,     tympanitis     after 
operation  on,  516 

Binder,   many-tailed,   SO 

Bladder,    drainage    of,    after    prosta- 
tectomy, 576 


641 


642 


INDEX 


Bladder,  operations  on,  566 

permanent  suprapubic  drainage  of, 

571 
temporary   suprapubic  drainage   of, 
567 
Blood  examination,  record   of,  4 

significance  of,  5 
Blood-vessel    anastomosis    by    suture, 

238 
Brain  operations,  328 

discharge     of     cerebrospinal     fluid 
after,  341 
Brain  prolapse,  343 
care  of,  344 

ultimate  outcome  of,  347 
Brain  substance,  softening  of,  336 
Breast,  excision  of,  395 
Bronchitis,  care  of,  10 


Calcium  chlorid,  70 

in  hemophilia,  23 
Canton  flannel  gloves,  132 
Cannula    anastomosis    in   transfusion, 

242 
Caps,  68 

Caps  and  masks,  133 
Carbolic  acid,   117 
Cardiac  and  arterial  disease,  15 

diet  in,  16 
Cardiac  tone,  Katzenstein's   test   for, 
17 

Riva-Bocei  test  for,  18 
Care  of  hair  before   operations,  43 
in  operations  on  face,  358 

of  mouth  before  operations,  43 

of  prolapse  of  brain,  344 

of  surgeon's  hair  and  beard,  44 
Castration,  5S0 
Catallou's  formula  for  rectal  feeding, 

295 
Catgut,  86 

chromieized,  S9 

diameter  of,   S6 

in  hermetically  sealed  tubes,  93 

iodized,  95 

plain,  88 

removal  of  fats  from,  88 

sterilization  of,  88 


Catgut,     sterilization     of,     in     cumol, 
91 
with  mercury,  89 

stored  in  jars,  91 
Catgut  drainage,  194 
Catharsis,  41 

after  celiotomy,  444 

after  enterectomy,  495 

after  rectal  operations,  544 
Catheter,  self-retaining,  SI 
Cavities,  training  of  manipulations  in, 

36 
Celiotomy,  422 

adhesions  following,  473 

administration  of  opiates  after,  433 

after-treatment  of,  439 

catharsis  after,  444 

feeding  after,  446 

peritonitis  after,  451 

phlebitis  after,  470 

retention  of  urine  after,  443 

secondary    repair    of    wound    after, 
449 

time  of  leaving  bed  after,  447 

tympanitis   after,   445 

vomiting  after,  442 
Celiotomy  sheet,  84 
Cerebrospinal  fluid,  discharge  of,  341 

retention  of,  335 
Cervical  lymphatics,   excision  of,  374 

preparation  for,  375 
Changing  dressings,  material  for,  301 
Cholecystectomy,  515 
Cholecystenterostomy,  515 
Cholecystotomy,  513 
Choledocotomy,  515 
Chole-enterostomy,  515 
Chromic  gut,  in  tissues,  94 
Chromieized  catgut,  90 
Cigarette  drain,  80,  190 
Circumcision,  582 
Cleansing    and    drainage    of    infected 

wounds,  305 
Cleansing  hands,  126 

chemical,  129 

immersion  bowls  for,  130 

material  for,  127 

mechanical,    129 

wash  stand  for,  12S 
Cleansing  mouth,  362 
Cleansing  nose,  362 


INDEX 


643 


Cleansing  skin,  47 

care  of  raw  surfaces  in,  51 

ether  in,  50 

gauze  for,  49 

in  infected  cases,  51 

Kelly  pad  in,  48 

Moynihan's  method  of,  50 

nail  brushes  for,  49 

rubber   sponge   for,   49 
Cleansing  wounds  of  mouth,  370 
.  Janet-Frank  syringe  for,  370 
Cleft  palate,  367 

care  of  wound  in,  369 
Clover's   crutch,  522 
Club-foot,  597 

dressing  for,  598 
Cocain,  30 

Coe's  needle  with  handle,  205 
Colectomy,   505 
Colon,  irrigation  of,  after  colostomy, 

503 
Colostomy,  499 

irrigation  of  colon  after,  502 
Colostomy  pad,  502 
Combined  dressing,  77 
Continuous  suture,  211 
Corrosive  sublimate  gauze,  224 
Cotton  for  dressings,  225 
Cranial    bones,    care    of    wounds    of, 
326 

necrosis  of,  332 
Cranial  contents,  operations  on,  328 
after   care  in,   330 
retention    of    cerebrospinal    fluid 

after,  335 
secondary  hemorrhage  after,  333 
Cranium,  application  of  dressings  to, 
348 

retention  of  dressings  on,  352 
Crile  mask,  137 

Cumol  sterilization  of  catgut,  91 
Cumolizer,  91 
Cystitis     after     perineal     operations, 

537 
Cystotomy,  suprapubic,  566 


Decortication   of  lung,  408 
Deformity  following  thoracotomy,  413 
43 


De  Garmo's  femoral  needle,  206 
Depilatory  mixture,  48 
Diabetes,  33 

diet  in,  34 
Diarrhea      after      gastroenterostomy, 

491 
Diet  after  entereetomy,  485 

before  operations,  44 

in  cardiac  and  arterial  disease,  16 

in  diabetes,  34 

of  alcoholics,  26 

sterile,  430 
Dilatation  of  stomach  and  gut,  277 
Donor,  in  transfusion,  250 
Double  roller  head  bandage,  349 
Douche  bags,  83 
Drain,  cigarette,  80 

rubber  tube,  80 
Drainage,  in  infected  cases,  188 

in  uninfected  cases,  187 

indications  for  kinds  of,  199 

of  abdomen,  433 

of  amputation  stumps,  609 

of  operative  wounds,   186 

of  pelvic  abscess,  529 

with  catgut,  194 

with  "  cigarette,"   196 

with  glass  tubing,  190 

with  rubber  tissue,  195 

with  rubber  tubing,  190 

with  silk-worm  gut,  193 

with  textile  fabric,  196 
Drainage  agents,  189 

indications  for  use  of,  199 
Drainage  tube,  193 
Dressing,    after    excision    of    breast, 
397 

after  perineal  operations,  525 

cotton  for,  225 

of  abdominal  wound,  436 

of  wounds  of  face,  359 

oil  silk  for,  226 

paraffin  paper  for,  226 

preparation  for  change  of,  300 

rubber  tissue   for,  226 
Dressing  sterilizer,  63 
Dressing  table,  146 

draping  of,  158,  160 
Dreyfuss  depilatory  mixture,  48 
Dry  heat  sterilization,  61 
Dupuytren's  contraction,  589 


644 


INDEX 


E 

Edema  and  softening  of  brain,  336 
Emergency      sture      in     hermetically 

sealed  glass  tube,  95 
Endocarditis  following  operations,  19 
Enema  preliminary  to  operation,  42 
Enterectomy,  494 

catharsis  after,  495 

diet  after,  495 

fecal  fistula  after,  496 
Enteroclysis,  264 
Ermold  needle  holder,  208 
Esophagotomy,  392 

care  of  wounds  after,  393 
Ether  for  cleansing  skin,  50 

avoidance  of  burns  in,  50 
Excision  of  breast,  395 
dressing  after,   397 

of  ribs,  400 
Excision  and  resection  of  joints,  601 
Exothyropexy,  391 
Exposure  of  operative  wounds,  302 
Extremities,  operations  on,  589 
Eye,  care  of,  after  intracranial  neu- 
rectomy, 356 


Face,  bandaging  of,  359 

operations  on,  358 

suturing  wounds  of,  361 
Fecal  fistula,  after  enterectomy,  496 

after  vaginal  section,  537 
Feeding  after  celiotomy,  446 

after  gastrostomy,  483 

after  intubation  of  larynx,  379 

after  operations,  288 

by  mouth,  288 

by  rectum,  291 
Femur,  nailing  of,  634 
Finger  cots,  136 

Fissure  of  Rolando,  localization  of,  317 
Fissure  of  Sylvius,  localization  of,  317 
Fistula  in  ano,  550 
Flat-foot,  593 

manipulations  for,  597 

shoes  after,  596 

spring  for,  595 
Fleiner's   formula  for   rectal   feeding, 
297 


Fluffed  gauze,  223 
Formulae  for  rectal  feeding,  295 
Fracture  of  patella,  630 
Fractures,  union  of,  633 


Gall    bladder    and    biliary    passages, 

operations  on,  512 
Gastroenterostomy,  487 

diarrhea  after,  491 

hemorrhage  after,  488 

intestinal  obstruction  after,  490 

regurgitant  vomiting  after,  489 

ulcer  of  jejunum  after,  491 
Gastro-intestinal    canal,    bacteriology 
of,  425 

special  preparation  of,  424 

sterility  of,  430 
Gastrostomy,  481 

feeding  after,  483 

rubber  plug  after,  484 
Gauze,  fluffed,  223 

for  cleansing  skin,  49 

for  dressings,  75,  223 

for  packing,  75 

sterile,   224 
Gauze  pads,  70 

Gelatin  injections  in  hemophilia,  23 
General  preparation  of  patient,  42 
Glass  tubing  for  drainage,  190 
Glisson  sling  for  torticollis,  374 
Gloves,  Canton  flannel,  132 

during  operation,  133 

rubber,  69 
Gold  wire,  102 

sterilization  of,  103 
Gowns,  68,  132 
Grafting  ureter  into  bladder,  564 


H 

Hagedorn  needle,  203 

with  Gentile  handle,  205 
Hair,    care    of,    before    operation,    43 
in  operations  on  face,  358 
protection  of,  during  operation,  55 
removal    of,    with   depilatory    mix- 
ture,  48 
shaving  of,  47 


INDEX 


645 


Hallux  valgus,  591 

shoes  after,  592 
Halsted-Leur  needle  holder,  208 
Hands,  cleansing  of,  126 
Harelip,  367 

dressing  of,  367 
Harelip  pins,  216 

Head,  retention  of  dressings  of,  348 
Hemolysis,  255 
Hemophilia,  21 

blood  test  in,  22 

calcium  chlorid  in,  23 

gelatin  injections  in,  23 

thyroid  extract  in,  21 
Hemorrhage  after  gastroenterostomy, 

488 
Hemorrhoids,  removal  of,  552 
Hepaticostomy,  515 
Hereditary  obesity,  31 
Hip- joint  amputations,  628 
History,  method  of  ke*eping,  3 
History  cards,  3 
Horsehair,  102 

sterilization  of,  102 
Hospital  operating  room,  139 
Hydatid  cysts  of  liver,  508 
Hydrocele,  579 
Hypodermic  injections,  235 
Hysterectomy,  519 

vaginal,  532 
Hysteromyomectomy,  519 


Improvised  sick  bed,  40 
Indications  for  kinds  of  drains,  199 
Infected  cases,  cleansing  skin  in,  51 

drainage  in,  188 
Infected   operative   wounds,   cleansing 
and  drainage  of,  305 

packing  of,  308 
Infusion,  by  needling  artery,  263 

in  shock,  259 

instruments  used  in,  260 

solution  for,  262 
Injection  of  mercury  in  syphilis,  20 
Instep  amputations,  616 
Instrument  sterilizers,  56 
Instrument  table,   154 

draping  of,   154 


Instrument  tray,  adjustable,  148 

draping  of,   156 
Instruments  used  in  infusion,  260 

in  transfusion,  239 
Interrupted  suture,  215 
Intestinal    obstruction    after    gastro- 
enterostomy, 490 
Intestines,  acute  dilatation  of,  277 

treatment  of,  281 
Intracranial  neurectomy,  356 

care  of  eye  after,  356 
Intubation  of  larynx,  378 

feeding  after,  379 
Iodin  catgut,  95 

Iodoform  and  its  modifications,  219 
Iodoform  gauze,  76 
Irrigation,  151 

in  perineal  operations,  525 
Irrigator,  151 
Island  of  Reil,  localization  of,  324 


Jaccoud's  formula  for  rectal  feeding, 

296 
Joints,  resection  of,  601 


K 


Kangaroo  tendon,  96 

Katzenstein's  test  of  cardiac  tone,  17 

Kelly  pads,  48 

Kelly's  needle  holder,  209 

Kemp's  tube,  554 

Kidney,  operations  on,  556 

renal  colic  after,  560 
Kidney   position,  557 
Knee-bearing  stumps,  623 
Knives,  sterilization  of,  59 
Kroenlein's  construction,  316 


Laminectomy,  415 

water  bed  after,  415 
Laryngectomy,  383 

avoidance  of  pneumonia  after,  385 
Larynx,  artificial,  386 

intubation  of,  378 

operations  on,  378 


646 


INDEX 


Lateral  ventricles,  localization  of,  324 
Lathier's  formula  for  rectal  feeding, 

296 
Lavatory  for  surgeon,  149 
Leg,  amputations  of,  621 
Ligature  material,  86 
Lithotomy  position,   521 

exaggerated,  574 
Liver,  abscess  of,  509 

hydatid  cysts  of,  508 

operations  on,  508 

resection  of,  511 
Lubricating  agents,  82 
Luer's  needle  holder,  208 
Lung,  decortication  of,  407 
Lung    complications     following    celi- 
otomy, 461 


M 


Major  operations,  requisites  for,  66 

Many-tailed  binder,  80 

Marion  suprapubic  drain,  568 

Mask,  Crile's,  137 

Massage  for-  abdominal  adhesions,  474 

Mastoid  operations,  352 

after-care  of  wound  in,  353 

radical,  355 
Material      necessary      for      changing 

dressings,  301 
Mercury,  119 
Method    of   handling   steam   pressure 

sterilizers,  64 
Microscopical  findings  of  tumors,  4 
Mikulicz  tampon,  268 

removal  of,  268 
Miscellaneous   operations,  630 

in  mouth,  369 
Moist  heat  sterilization,  61 
Morphin,  administration  of,  30 

withdrawal  of,  30 
Mouth,  care  of,  before  operations,  43 

cleansing  of,  362 
Moynihan's  method  of  cleansing  skin, 

50 
Murphy  treatment  of  peritonitis,  457 
Murphy's  rubber  dam,  52 
Mushroom  catheter,  569 
Myxedema  after  thyroidectomy,  389 

treatment  of,  390 


N 


Nail  brush,  69 

for  cleansing  skin,  49 
Narcotist,    preparation    of,    in    head 

operations,  311 
Narcotist's  table,  148 

with  necessary  materials,  156 
Neck,    dressing    after    operations    on, 
377 

operations  on,  373 
Needle   holders,   207 
Needle   wounds,  204 
Needles  for  suturing,  203 
Needling  of  artery  in  infusion,  263 
Nephrectomy,  562 

peritonitis   after,  563 

uremia  after,  562 
Nephritis,  13 
Nephropexy,  557 
Nephrotomy,    560 
Neurectomy,  intracranial,  356 
Non-absorbable  suture  material,  97 
Nose,  cleansing  of,  362 


Obesity,  31 

acquired,  31 

classification  of,  31 

diet  in,  32 

hereditary,  31 

thyroid  extract  in,  32 

withdrawal  of  carbohydrates  in,  32 
of  fats  and  oils  in,  42 
Office  arrangement,  6 
Oil  silk  for  dressing,  226 
Operating  room,  arrangement   of  ap- 
paratus in,  152 

illumination  of,   140 
artificial,  141 

in  hospital,  139 

in  private  practice,  169 
cleansing  of,   172 

tables  arranged  in,  153 
Operating  table,  142 

extemporized,    177 

portable,  173 
Operating  suits,  125 
Operations  on  abdomen,  422 


INDEX 


647 


Operations  on  anus,  548 

on  bladder,  567 

on  cavities,  training  in,  36 

on  cranial  contents,  328 

on  cranium,  316 

on  extremities,  591 

on  face,  358 

on    gall    bladder    and    biliary    pas- 
sages, 512 

on  kidney,  556 

on  larynx  and  trachea,  378 

on  neck.  373 

on  rectum,  541 

by  perineal  route,  548 

on  scalp,  311 

on  scrotum  and  penis,  579 

on  thorax,  395 

on  ureter,  564 

on  uterus,  518 
Operative      wounds,      cleansing      and 
drainage  of,  305 

drainage  of,  186 

exposure  of,  302 

suturing  of,  201 

time  of  dressing,  299 
Operator,  preparation  of,  124 
Operator  and  assistants  during  opera- 
tion, 169 
Opiates  after  celiotomy,  443 
Osteomyelitis  of  spine,  420 
Osteoplastic  rhinoplasty,  366 
Osteotomy,  600 
Outfit  for  sterilization,  110 
Ovariotomy,  518 


Packing  of  infected  wounds,  309 
Pagenstecher  thread,  100 

sterilization  of,  101 
Pain,  treatment  of,  285 
Paraffin  paper  for  dressing,  226 
Parotitis,  after  abdominal  operations, 

465  . 
Patella,  fracture  of,  630 

lateral  manipulation  of,  632 
Pathological  report  record,  4 
Pelvic  abscess,  drainage  of,  529 
Penis,  plastic  operations  on,  583 
Perineal  operations,  521 


Perineal  operations,  care  of,  526 

care  of  wound  in,  527 

cystitis  after,  537 

dressing  after,  525 

fecal  fistula  after,  537 

irrigation  in,  525 
Perineal  prostatectomy,  573 

drainage  after,  575 

position  of  patient  for,  574 
Peritoneum,  flushing  of,  453 
Peritonitis   after  celiotomy,  451 

after  nephrectomy,  563 

Murphy  treatment  of,  457 

prevention  of,  451 

treatment  of,  456 
Peroxid  of  hydrogen,  121 
Phlebitis   after   celiotomy,   470 
Pitchers,  68 

for  handling  water,  115 
Plastic  operations  on  penis,  583 
Pleuritis  after  operation,   19 
Postoperative  care,  bedside  table  for, 
232 

feeding  in,  288 

in  necrosis  of  cranial  bones,  332 

of  pain,  285 

of  thirst,  284 

of  vomiting,  272 

of  wounds,  298 
Powders,   antiseptic,   215. 

application  of,  220 

sprinkler  for,  220 
Preparation  of  operative  field.  46 

of  operator  and  assistants,   124 

of  patient,  final,  168 
general,  42 

Kocher's  method  of,  42 
Moynihan's  method  of,  43 

of  scalp,  312 

of  skin  in  infected  cases,  51 
Preparatory  care,  in  bronchitis,  10 

in  cardiac  and  arterial  disease,  15 

in  cases  of  rheumatism  and  gout,  18 

in  nephritis.  13 

in  pulmonary  tuberculosis,  11 

in  tuberculosis  of  glands  and  bones, 
12 

of  alcoholics,  24 

of  diabetics.  33 

of  hemophiliacs.  22 

of  obese  patients,  34 


648 


INDEX 


Preparatory    care   of    patients    using 
tobacco,  28 

of  syphilitics,  20 
Preparatory  diet,  44 
Principles  of  sterilization,  60 
Prognostic  value  of  assembled  history 

record,  5 
Prolapse  of  brain,  343 

of  rectum,  554 
Prostatectomy,  perineal,  573 

drainage  after,  575 
Protective  dressing,  221 

gauze  for,  223 

method  of  application  of,  222 
Protoscope,  541 
Pulmonary  tuberculosis,  11 


R 


Ratjen's    formula   for   rectal   feeding, 

297 
Raw  surfaces  in  cleansing  skin,  51 
Reception  room  and  office  plan,  8 
Recipient  in  transfusion,  253 
Recording  the  history,  2 
Record  of  blood  examination,  4 

of  urinary  analysis,  4 
Rectal  bougie,  294 
Rectal  feeding,  291 

formula   for,  95 

in  pulmonary  tuberculosis,  11 
Rectal  operations,  catharsis  after,  544 
Rectal  tube,  82 
Rectum,  cleansing  of,  555 

operations  on,  541 
by  perineal  route,  548 
by  sacral  route,  542 

prolapse  of,  554 
Removal  of  hair  with  depilatory  mix- 
ture, 48 

of  sutures,  304 
Renal    colic   following   kidney   opera- 
tions, 560 
Repair  of  wounds  in  syphilitics,  21 
Requisites   for  major  operations,  66 
Resection  of  liver,  511 
Restraint  of  patient  after  operation, 

441 
Retention   of   cerebrospinal   fluid,   335 

of  urine  after  celiotomy,  443 


Retracted     heels     after     amputation, 

618 
Rheumatism  and  gout,  18 
Rheumatism  following  operation,  19 
Rhinoplasty,  364 

osteoplastic,  366 
Riegl's    formula    for    rectal    feeding, 

295 
Riva-Rocci  apparatus,  18 
Roll  gauze,  77 
Round  needles,  205 
Rubber  dam,  Murphy's,  52 
Rubber    drainage    tube,    fenestration 

of,  191 
Rubber  gloves,  69 
Rubber  sheets,  84 

Rubber  sponge  for  cleansing  skin,  49 
Rubber  tissue  drainage,  195 

for  dressing,  226 
Rubber  tube  drain,  80 
Rubber  tubing  for  drainage,  190 


Sacral  approach  to  rectum,  542 
Saline  solution,  81,  122 
Sand's  needle  holder,  208 
Scalp,  care  of  wound  of,  314 

outlining  of  fissures  on,  317 

preparation  of,  312 

in  minor  operations,  313 
Scalp   wounds,  drainage  of,  in  infec- 
tion, 315 
Schlesinger's  formula  for  rectal  feed- 
ing, 297 
Scissors  for  removing  sutures,  304 
Scrotum,  operations  on,  579 
Scultetus   binder,   438 
Secondary  bleeding,  267 

following  brain  opei-ations,  333 
Self-retaining  catheter,  81 
Shaving,  47 

Shock,    cannula   anastomosis    of   ves- 
sels in,  242 

direct  suturing  of  blood-vessels  in, 
238 

enteroclysis  in,  264 

following  operations,  227 

infusion  in,  259 

needling  of  arteiy  in,  263 


INDEX 


649 


Shock,  transfusion  in,  237 

general  management  of,  246 

treatment  of,  233 

use  of  adrenalin  in,  234 
Shock  bed,  229 
Sick  bed,  39 
Sick  room,  38 

cleansing  of,  38 

temperature  of,  54 
Silk,  98 

braided,  98 

in  hermetically  sealed  glass   tubes, 
100 

sterilization  of,  99 

twisted,  98 
Silk- worm  gut,  97 

in  hermetically  sealed  glass  tubes,  97 

sterilization  of,  97 
Silk-worm  gut  drainage,  193 
Silver  wire,  102 

sterilization  of,  103 
Singer's    formula    for   rectal    feeding, 

297 
Single  roller  head  bandage,  348 
Skin,  cleansing  of,  47 

in  infected  cases,  51 
Skin  grafting,  636 
Skull,  frontipetal  type  of,  320 

occipitopetal  type  of,  321 
Soap,  69 

Solution  for  infusion,  262 
Solutions  of  carbolic  acid,  118 

of  mercury,  119 
Steam   sterilizers,  62 
Sterile  cotton,  75 
Sterile  diet,  430 
Sterile  gauze,  224 
Sterile  nurse,  attire  of,  138 
Sterile  saline  solution,  81 
Sterile  towels,  81 

Sterile  water,  in  private  practice,  180 
Sterilization,  in  general,  60 

of  catgut,  88 
in  cumol,  91 

of  dressings,  63 

of  gastro-intestinal  canal,  430 

of  gold  wire,  103 

of  horsehair,  102 

of  instruments,  56 

of  knives,  59 

under  pressure,  59 


Sterilization   of  Pagensteeher  thread, 
101 

of  silk,  99 

of  silver  wire,  102 

of  water,  104 
Sterilization  outfit,  110 

under  steam  pressure,  62 
Stomach,  acute  dilatation  of,  277 

treatment  of,  280 
Stumps,  623 

tapering,  621 
Supporters,  abdominal,  475 
Suprapubic  cystotomy,  566 
Suprapubic  drainage,  permanent,  571 

temporary,  567 
Surgeons,  complete  attire  of,   137 

hair  and  beard  of,  care  of,  44 
Surgeon's  lavatory,  149 
Surgeon's  needles,  203 
Surgeon's  outfit  for  sterilization,  112 
Suture,  continuous,  211 

improperly   tied,  202 

interrupted,  215 

properly  tied,  202 

removal  of,  304 
scissors  for,  304 
Suture  and  ligature  material,  85 
Suture  material,  absorbable,  86 
Sutures  to  relieve  tension,  215 
Suturing,  needles  for,  203 

of  operative  wounds,  201 

of  wounds  of  face,  361 
Syphilis,   19 

injections  of  mercury  in,  20 


Tampon,  Mikulicz,  268 

T-bandage,  38 

Temperature  of  sick  room,  54 

Tension  on  sutures,  215 

Textile  fabric  drainage,  196 

Thermometer,  82 

Thiersch's  fluid,  120 

Thigh  stumps,  625 

Thirst,   283 

treatment  of, '283 
Thoracic  wall,  resection  of,  408 
Thoracoplasty,  406 
Thoracotomy,   399 

aspiration  after,  401 


650 


INDEX 


Thoracotomy,  deformity  after.  413 

Fell-O'Dwyer  apparatus  in,  409 
Thorax,  wounds   of,  395 
Thyroid,  cysts  of,  391 
Thyroid  extract,  22 

in  hemophilia,  22 

in  obesity,  32 
Thyroidectomy,  387 

fever  after,  388 

myxedema  after,  389 

pneumonia  after,  388 
Tobacco,  28 

use  of,  after  operation,  29 
before  operation,  25 

withdrawal  of,  29 
Torticollis,   373 

Glisson  sling  for.  374 

manipulations    after    correction    of, 
374 
Tournier's  formula  for  rectal  feeding, 

296 
Towels,  sterile,  81 
Trachea,  operations  on,  378 
Tracheotomy,  380 

position  after,  381 

use  of  moist  air  after,  381 
Tracheotomy  tube,  removal  of,  382 
Transfusion,  237 

acute  dilatation  of  heart  in,  253 

direct,  238 

donor  in,  250 

general  management  of,  246 

hemolysis  in,  255 

local  anesthesia  in,  248 

recipient  in.  253 

requisite  instrument  for,  238 
Triplex  drainage  tube,  193 
Tube  drainage,  189 
Tuberculosis  of  glands,  bones,  etc.,  12 

pulmonary,  11 

care  of,  before  operations,   11 
Tuberculous  cervical  adenitis,  375 
Tying  of  sutures,  201 
Tympanitis,  after  celiotomy,  445 

after    operations    on    biliary    pas- 
sages, 516 


U 

Ulcer   of  jejunum    after   gastroenter- 
ostomy, 491 


Uninfected  cases,  drainage  in,  187 
Uremia  after  nephrectomy,  562 
Ureter,  grafting  of,  564 

operations  on,  564 
Ureteral  operations,  fistula  after,  564 

position  of  patient  in,  564 
Urethrotomy,   584 
Urinary  analysis,  significance  of,  5 
Urinary  fistula,  561 

after  ureteral  operations,  564 
Urinary  record,  4 
Utensil  sterilizer,  151 


Vaginal  hysterectomy,  532 

Varicocele,  580 

Vomiting,  after  celiotomy,  442 

after   gastroenterostomy,   489 

postoperative,  272 
Vomitus,  character  of,  276 
Vulvar  pad,  84 

W 

Wales'  rectal  bougie,  294 

Wash  stand  for  cleansing  hands,  128 

Water,  104 

apparatus  for  sterilization  of,  105, 
106,  197,  198 

drawing  from  sterile  retort,  116 

in  pitchers,  115 

plain  sterile,  121 

sterilization  of,  104 
by  heat,  105 
Wipes,   72 
Wounds,  in  diabetics.  36 

made  by  needles,  204 

of  abdomen,  closure  of,  435 

of  cranial  bones,  326 

of  esophagus,  393 

of  face,  dressing  of,  359 
suturing  of,  361 

of  mouth,  cleansing  of,  370 

of  scalp,  314 

postoperative  care  of,  298 


Zinc  chlorid,   120 


(1) 


DUE  DATE 


COLUMBIA  UNIVERSITY  LIBRARIES  (hsl.stx) 

RD  66  H29  C.1 

Preparatory  and  after  treatment  in  opera 


2002125072 


